Highmark Health
Part-Time Weekend Medical Director (Remote)
Highmark Health, New York, New York, United States
Overview
Highmark Inc. - The physician utilizes management responsibilities to ensure utilization management aligns with current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria to evaluate medical necessity and appropriateness of requested treatment or service. Depending on case nature, telephonic peer-to-peer discussions may be required. This role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates as the physician member of the multidisciplinary team for case and disease management. The physician advises on high-risk cases and may be assigned special projects to support member care. 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 determinations while 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 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 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 specific 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 Language
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): Rarely Physical work site required: No Lifting: up to 10 pounds: Constant 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 job 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. All employees must comply with HIPAA and the company's privacy and information security policies. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct and applicable laws, rules, and regulations as well as company policies and training requirements. Pay
Minimum: $170,000.00 Maximum: $342,274.00 Base pay is determined by qualifications, experience, expected contributions, internal equity, market, and business considerations. The salary range may vary by location. Highmark Health and its affiliates are an Equal Opportunity Employer. EEO is The Law. See poster: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf We are committed to accessibility. For accommodation requests, contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Notice for Employees, Contractors, and Applicants Req ID: J254551 #J-18808-Ljbffr
Highmark Inc. - The physician utilizes management responsibilities to ensure utilization management aligns with current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria to evaluate medical necessity and appropriateness of requested treatment or service. Depending on case nature, telephonic peer-to-peer discussions may be required. This role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates as the physician member of the multidisciplinary team for case and disease management. The physician advises on high-risk cases and may be assigned special projects to support member care. 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 determinations while 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 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 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 specific 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 Language
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): Rarely Physical work site required: No Lifting: up to 10 pounds: Constant 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 job 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. All employees must comply with HIPAA and the company's privacy and information security policies. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct and applicable laws, rules, and regulations as well as company policies and training requirements. Pay
Minimum: $170,000.00 Maximum: $342,274.00 Base pay is determined by qualifications, experience, expected contributions, internal equity, market, and business considerations. The salary range may vary by location. Highmark Health and its affiliates are an Equal Opportunity Employer. EEO is The Law. See poster: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf We are committed to accessibility. For accommodation requests, contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Notice for Employees, Contractors, and Applicants Req ID: J254551 #J-18808-Ljbffr