Highmark
Overview
Part-Time Weekend Medical Director (Remote) at Highmark. This physician-led role ensures utilization management responsibilities are performed to the highest clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria to evaluate medical necessity and appropriateness of the requested treatment or service. Depending on the case, telephonic peer-to-peer discussions may be required. The role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the physician participates as a member of the multidisciplinary team for case and disease management, advising on high-risk cases. The incumbent may be assigned special projects to support and improve member care. 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, adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). 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 the 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: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Substitutions: None. Preferred: Masters 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 managed care industry. Licenses and Certification
Required: Medical Doctor or Doctor of Osteopathic Medicine (DO). Awarded Board Certification at least once in 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 may be required based on business need. Skills
Critical Thinking Case Management Customer Service Oral & Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care Travel
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 & Ethics: This job adheres to the code of business conduct and company policies. As a component of job responsibilities, employees may have access to confidential information and must protect it in accordance with HIPAA and the company privacy policies. Pay Range: Minimum $170,000; Maximum $342,274. Base pay determined by qualifications and other factors. The salary range does not reflect geographic differentials that Highmark may apply. EEO is The Law. Highmark Health is an Equal Opportunity Employer. We encourage applications from Minorities, Women, Protected Veterans, and individuals with disabilities. Seniority level
Mid-Senior level Employment type
Part-time Job function
Health Care Provider Industries
Insurance #J-18808-Ljbffr
Part-Time Weekend Medical Director (Remote) at Highmark. This physician-led role ensures utilization management responsibilities are performed to the highest clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria to evaluate medical necessity and appropriateness of the requested treatment or service. Depending on the case, telephonic peer-to-peer discussions may be required. The role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the physician participates as a member of the multidisciplinary team for case and disease management, advising on high-risk cases. The incumbent may be assigned special projects to support and improve member care. 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, adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). 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 the 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: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Substitutions: None. Preferred: Masters 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 managed care industry. Licenses and Certification
Required: Medical Doctor or Doctor of Osteopathic Medicine (DO). Awarded Board Certification at least once in 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 may be required based on business need. Skills
Critical Thinking Case Management Customer Service Oral & Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care Travel
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 & Ethics: This job adheres to the code of business conduct and company policies. As a component of job responsibilities, employees may have access to confidential information and must protect it in accordance with HIPAA and the company privacy policies. Pay Range: Minimum $170,000; Maximum $342,274. Base pay determined by qualifications and other factors. The salary range does not reflect geographic differentials that Highmark may apply. EEO is The Law. Highmark Health is an Equal Opportunity Employer. We encourage applications from Minorities, Women, Protected Veterans, and individuals with disabilities. Seniority level
Mid-Senior level Employment type
Part-time Job function
Health Care Provider Industries
Insurance #J-18808-Ljbffr