Highmark Health
Part-Time Weekend Medical Director (Remote)
Highmark Health, New York, New York, United States
Overview
Highmark Inc. seeks a physician to join a medical management team. The role ensures utilization management responsibilities are performed in accordance with current clinical standards. The physician reviews escalated cases electronically and by applying Medical Policy criteria to evaluate medical necessity and appropriateness. Telephonic peer-to-peer discussions may be required. The physician ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates as a physician member of the multidisciplinary team for case and disease management. The physician may lead or participate in special projects to support member care. Responsibilities
Conduct electronic review of escalated cases against medical policy criteria, including possible telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, review appeals and grievances, and other reviews as assigned. Prepare clear rationales for member and provider notifications in compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Ensure all aspects of medical management align with community standards of care. Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the team on cases requiring physician expertise. Contribute to protocol and guideline development to ensure consistency in the review process. Actively manage projects or participate on project teams that require physician subject matter expertise. Other duties as assigned. Education
Required Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) Substitutions None Preferred Master's Degree in Business Administration/Management or Public Health Experience
Required 5 years in clinical, direct patient care (hospital, outpatient, or private practice) Preferred 1 year in medical management in a health insurance plan; strong knowledge of the managed care industry Licenses and Certification
Required Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification 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 required. Additional state licensure(s) may be required based on business need. Preferred None Skills
Critical Thinking Case Management Customer Service Oral & Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care Other
Language (Other than English): None Travel Required: 0% - 25% Physical, Mental Demands and Working Conditions
Position Type: Office-Based Notes: Teaches/trains others regularly. Travel to various work sites as needed. Physical requirements include lifting up to 10 pounds frequently, with occasional lifting of 10 to 25 pounds; lifting of 25 to 50 pounds rarely. Compliance and Privacy
Disclaimer: This job description reflects the general nature and essential duties of the work. Compliance requirements include adherence to the code of business conduct and company policies. Employees may be exposed to confidential information and must comply with HIPAA and the companys privacy and information security policies. Employees are responsible for complying with applicable laws, regulations, and company policies. Pay
Pay Range Minimum: $170,000.00 Pay Range Maximum: $342,274.00 Base pay is determined by qualifications, experience, and internal equity, among other factors. The salary range may vary by location. EEO
Highmark Health is an Equal Opportunity Employer. We prohibit discrimination based on protected veteran status, disability, race, color, age, religion, sex, national origin, sexual orientation/gender identity, or any other category protected by law. We provide affirmative action to employ and advance in employment individuals without regard to these characteristics. We include an EEO poster and accessibility information for applicants as part of our policy. Req ID: J254551 #J-18808-Ljbffr
Highmark Inc. seeks a physician to join a medical management team. The role ensures utilization management responsibilities are performed in accordance with current clinical standards. The physician reviews escalated cases electronically and by applying Medical Policy criteria to evaluate medical necessity and appropriateness. Telephonic peer-to-peer discussions may be required. The physician ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates as a physician member of the multidisciplinary team for case and disease management. The physician may lead or participate in special projects to support member care. Responsibilities
Conduct electronic review of escalated cases against medical policy criteria, including possible telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, review appeals and grievances, and other reviews as assigned. Prepare clear rationales for member and provider notifications in compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Ensure all aspects of medical management align with community standards of care. Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the team on cases requiring physician expertise. Contribute to protocol and guideline development to ensure consistency in the review process. Actively manage projects or participate on project teams that require physician subject matter expertise. Other duties as assigned. Education
Required Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) Substitutions None Preferred Master's Degree in Business Administration/Management or Public Health Experience
Required 5 years in clinical, direct patient care (hospital, outpatient, or private practice) Preferred 1 year in medical management in a health insurance plan; strong knowledge of the managed care industry Licenses and Certification
Required Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification 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 required. Additional state licensure(s) may be required based on business need. Preferred None Skills
Critical Thinking Case Management Customer Service Oral & Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care Other
Language (Other than English): None Travel Required: 0% - 25% Physical, Mental Demands and Working Conditions
Position Type: Office-Based Notes: Teaches/trains others regularly. Travel to various work sites as needed. Physical requirements include lifting up to 10 pounds frequently, with occasional lifting of 10 to 25 pounds; lifting of 25 to 50 pounds rarely. Compliance and Privacy
Disclaimer: This job description reflects the general nature and essential duties of the work. Compliance requirements include adherence to the code of business conduct and company policies. Employees may be exposed to confidential information and must comply with HIPAA and the companys privacy and information security policies. Employees are responsible for complying with applicable laws, regulations, and company policies. Pay
Pay Range Minimum: $170,000.00 Pay Range Maximum: $342,274.00 Base pay is determined by qualifications, experience, and internal equity, among other factors. The salary range may vary by location. EEO
Highmark Health is an Equal Opportunity Employer. We prohibit discrimination based on protected veteran status, disability, race, color, age, religion, sex, national origin, sexual orientation/gender identity, or any other category protected by law. We provide affirmative action to employ and advance in employment individuals without regard to these characteristics. We include an EEO poster and accessibility information for applicants as part of our policy. Req ID: J254551 #J-18808-Ljbffr