Medical Director, Clinical Services

Company : Highmark Inc. Job Description :

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 of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to 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. They will advise the multidisciplinary team on cases, particularly high‑risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.

ESSENTIAL RESPONSIBILITIES

Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that 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. Advise multidisciplinary team on cases that require 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. 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 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 Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care Language (Other than English) None Travel Required 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office‑Based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site‑to‑site Rarely Works primarily out‑of‑the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures and all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum $170,000.00 Pay Range Maximum $352,500.00 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. 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. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at View email address on click.appcast.io. California Consumer Privacy Act Employees, Contractors, and Applicants Notice #J-18808-Ljbffr Highmark Health