Medical Director

Overview

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 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

Substitutions

Preferred

Experience

Required

Preferred

Licenses and Certification

Required

Preferred

Skills

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

Compliance and Notices

Disclaimer : This 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 HIPAA and the company’s privacy and information security guidelines.

Code of Business Conduct : It is every employee’s responsibility to comply with the company’s Code of Business Conduct, including applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay

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 protected status and other categories as required by law. We strive to make this site accessible and provide accommodations upon request. For accommodations, contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID : J266916

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