Medical Director

Job Summary

This role is part of a physician team and ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards.

The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate medical necessity and appropriateness of requested treatments. The job includes potential telephonic peer‑to‑peer discussions, compliance with NCQA, URAC, CMS, DOH, DOL regulations, and participation as physician member of the multidisciplinary team for case and disease management.

Essential Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, including telephonic peer‑to‑peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, review appeals and grievances, and other reviews as assigned.
• Compose clear and concise rationales for member and provider determination notifications while adhering to required compliance standards.
• Participate as a member of the CMDM multidisciplinary team: attend huddles and grand rounds and advise team on cases requiring physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• Perform other duties as assigned.

Education

• Required: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• Preferred: Master’s Degree in Business Administration/Management or Public Health

Experience

• Required: 5 years in clinical direct patient care (hospital, outpatient, or private practice)
• Preferred: 1 year in medical management in a health insurance plan; strong knowledge of managed care industry

Licenses and Certification

• Required: Medical Doctor or Doctor of Osteopathic Medicine (DO)
• Board certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Active medical state licensure required; additional specific state licensure(s) may be required based on business need.
• Preferred: None

Skills

• Critical thinking
• Case management
• Customer service
• Oral & written communication
• Collaboration
• Listening
• Telephone skills
• General computer skills
• Clinical software
• Managed care

Travel

0% - 25%

Physical Demands

Office-based. Requires occasional teaching/training. Regular travel from office to various work sites; lifting <10 lbs constantly, 10–25 lbs rarely, 25–50 lbs rarely.

EEO Statement

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on veteran or disability status and on any category protected by applicable federal, state, or local law.