Medical Director

Highmark Health • Washington, NV

40d • $227,600 - $385,000 • Onsite

About The Position

As part of a physician team, the Medical Director ensures that utilization management responsibilities are performed in accordance with current clinical standards. The role reviews escalated cases electronically using Medical Policy criteria to evaluate the medical necessity and appropriateness of requested treatment or services. Depending on the case, telephonic peer-to-peer discussions may be required. The Medical Director ensures compliance with applicable NCQA, URAC, CMS, DOH, and DOL regulations.

In addition to utilization review, the Medical Director serves as the physician member of a multidisciplinary team for case and disease management, advising the team on cases—particularly high-risk cases. The role may also involve special projects to support and improve member care. The position is office-based, with no physical work site required, and travel is listed as 0%–25%.

Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).
• At least 5 years of clinical, direct patient care experience in a hospital, outpatient, or private practice setting.
• Board certification awarded 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; additional state licenses may be required based on business need.
• Skills in critical thinking, case management, customer service, oral and written communication, collaboration, listening, telephone use, general computer use, clinical software, and managed care.

Nice To Haves

• Master’s degree in Business Administration/Management or Public Health.
• At least 1 year of medical management experience in a health insurance plan.
• Strong knowledge of the managed care industry.

Responsibilities

• Review escalated cases electronically against medical policy criteria to determine medical necessity and appropriateness, including telephonic peer-to-peer discussions when needed.
• Complete initial case determinations, reviews of appeals and grievances, and other assigned reviews.
• Write clear and concise rationales for member and provider determination notifications while adhering to compliance standards.
• Ensure medical management processes are consistent with community standards of care.
• Participate in the CMDM multidisciplinary team, attend huddles and grand rounds, and advise the team on cases requiring physician expertise.
• Participate in developing protocols and guidelines to promote consistency in the review process.
• Manage projects and/or participate on project teams as a physician subject matter expert.
• Perform other duties as assigned.
• Comply with the company’s ethical and legal standards, code of business conduct, privacy policies, HIPAA requirements, and information security policies.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree