Medical Director

Highmark Health Medical Director Charleston, West Virginia Apply Now

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 or service. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with 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, advising the team on high-risk cases. 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 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, attending huddles and grand rounds, and advising on cases requiring 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

Preferred

EXPERIENCE

Required

Preferred

LICENSES AND CERTIFICATION

Required

SKILLS

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

Physical work site required : No

Lifting : up to 10 pounds : Constantly

Lifting : 10 to 25 pounds : Rarely

Lifting : 25 to 50 pounds : Rarely

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.

Pay Range Minimum : $170,000.00

Pay Range Maximum : $342,274.00

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 their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law.

EEO is The Law

Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity

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 number below.

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

J-18808-Ljbffr

Salary : $170,000 - $342,274