**Company :**

Highmark Inc.

**Job Description :**

**JOB SUMMARY**

This job leads a physician team and ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent oversees a team of Medical Directors who are responsible for reviewing escalated cases electronically and using Medical Policy criteria sets, evaluating 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 physician team must ensure compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times, and the Senior Medical Director will be responsible for ensuring that those measures are met. In addition to utilization review, the physician teams participate as physician members of CMDM multidisciplinary teams for case review. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the physicians may be assigned special projects to help support and improve the care of our members. As the leader of these physicians, the Senior Medical Director will manage performance accordingly, delegate projects, and determine which team members will participate in which multidisciplinary teams. Also, as a physician leader, the incumbent consults other departments across the organization and with key provider networks as needed. They may serve on committees or project teams as a subject matter expert, depending on specialty and prior experience.

**ESSENTIAL RESPONSIBILITIES**

Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

Participate on cross functional work teams as a physician subject matter expert and provide clinical leadership for relevant initiatives. At times, own/lead projects related to process improvement, system enhancements, and/or improvement of utilization management, quality of care and/or member services. Collaborate with providers to enhance care and population health management services.

Identify industry benchmarks and analyze and synthesize data and research to identify best practices relevant to clinical operations. Partner across the enterprise to develop, plan, and drive strategy.

Develop and lead a culture of continuous process improvement and care cost focus. Monitor, reinforce and model core behaviors that support and enable high-performing teams. Monitor and remediate regulatory compliance standards and develop tools and processes geared toward inter-rater reliability to promote consistent and appropriate utilization management decisions.

Other duties as assigned

**EDUCATION**

**Required**

Doctor of Medicine or Doctor of Osteopathic Medicine

**Substitutions**

None

**Preferred**

Master's Degree in Business Administration/Management or Public health

**EXPERIENCE**

**Required**

5 years of experience in an active medical practice

1 year of Management experience

**Preferred**

None

**LICENSES AND CERTIFICATIONS**

**Required**

Medical Doctor OR

Doctor of Osteopathic Medicine (DO), Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty credentialed in a Highmark network.

A current, unrestricted state medical license (Delaware)

**Preferred**

None

**SKILLS**

Critical Thinking

Case Management

Customer Service

Listening

Telephone Skills

General Computer Skills

Clinical Software

Email Software (Outlook)

MS Word

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

Rarely

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 position 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 as well as 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.

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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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Req ID: J242183