Medical Director, Medical Management

Highmark Health

Multiple Locations, USA
Base: $227,600.00 - $385,000.00; bonus/equity: not...
Electronic review of escalated cases
Medical policy criteria sets
Telephonic peer to peer discussions
Ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards

Job Summary

  • Ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards.
  • Reviews escalated cases electronically and using Medical Policy criteria sets to evaluate medical necessity and appropriateness.
  • Participates as the physician member of the multidisciplinary team for case and disease management, advising on high-risk cases.

Matching Summary

Ensures utilization management responsibilities are performed in accordance with the highest and most current clinical standards.

Salary

Base: $227,600.00 - $385,000.00; Bonus/Equity: Not specified; Benefits: Not specified

Skills & Requirements

Must-have

  • Electronic review of escalated cases
  • Medical Policy criteria sets
  • Telephonic peer to peer discussions
  • NCQA, URAC, CMS, DOH, DOL compliance
  • Multidisciplinary team participation
  • Community standards of care

Nice-to-have

  • Advise on high-risk cases
  • Protocol and guidelines development
  • Physician subject matter expert

Key Requirements

  • MD or DO degree
  • Board Certification
  • Active medical state licensure
  • 5 years clinical direct patient care
  • 1 year Medical Management experience

Work Rights

Not specified

Tailored Resume

Cover Letter