Medical Director

Company :

Highmark Inc.

Job Summary

This job, as part of a physician team, ensures that 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 the medical necessity and appropriateness of the requested treatment or service. Depending on the nature of the case, telephonic peer‑to‑peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management, advising the team on cases, particularly high‑risk cases, and may be assigned special projects to support and improve the care of members.

Essential Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, possibly including telephonic peer‑to‑peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review appeals and grievances, and other assigned reviews.
• Compose clear and concise rationales for member and provider determination notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations).
• Ensure all aspects of the medical management process are consistent with community standards of care.
• Participate as a member of the CMDM multidisciplinary team, attend huddles and grand rounds, and advise the team on cases requiring physician expertise.
• Participate in protocol and guideline development to ensure consistency in the review process.
• Actively manage projects and/or participate in project teams requiring a physician subject‑matter expert.
• Other duties as assigned.

Education

Required

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Substitutions

• None

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)
• Awarded 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 Skills
• CollaborationListening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Travel Required

0% – 25%

Physical, Mental Demands and Working Conditions

This role is office‑based, may involve occasional travel, and requires the ability to lift up to 50 pounds. The incumbent may need to teach or train others occasionally. The position requires regular participation in multisource team sessions and clinical decision‑making workflows.

Pay Range

Minimum: $227,600.00

Maximum: $385,000.00

EEO Statement

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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