Highmark Health
Part-Time Weekend Medical Director (Remote)
Highmark Health, New York, New York, United States
Overview
Company:
Highmark Inc. Job Summary:
This physician role, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatment or service. Depending on 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, they participate as the physician member of the multidisciplinary team for case and disease management, advise the team on cases, particularly high-risk cases, and 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 determinations, while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure that all aspects of the medical management process align 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 requiring physician expertise. Participate in protocol and guideline 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 Education
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 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.
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
0% - 25% Physical, Mental Demands and Working Conditions
Position Type: Office-Based Teaches / trains others regularly: Occasional Travel regularly from the office to various work sites or from site-to-site: Rarely Works primarily out of the office; 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 confidential information that must be protected at all times. All employees must comply with HIPAA and company privacy policies and information security guidelines. Furthermore, it is every employees responsibility to comply with the companys Code of Business Conduct and applicable laws, rules, and regulations. Pay Range
Minimum: $170,000.00 Maximum: $342,274.00 Base pay is determined by a variety of factors including qualifications, experience, and contributions, as well as internal equity, market, and business considerations. The salary range does not reflect geographic differentials that may apply by location. Highmark Health and its affiliates are an Equal Opportunity Employer. EEO is The Law. Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity. We value accessibility; for accommodations contact HR Services Online. Req ID: J254551 #J-18808-Ljbffr
Company:
Highmark Inc. Job Summary:
This physician role, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatment or service. Depending on 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, they participate as the physician member of the multidisciplinary team for case and disease management, advise the team on cases, particularly high-risk cases, and 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 determinations, while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure that all aspects of the medical management process align 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 requiring physician expertise. Participate in protocol and guideline 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 Education
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 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.
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
0% - 25% Physical, Mental Demands and Working Conditions
Position Type: Office-Based Teaches / trains others regularly: Occasional Travel regularly from the office to various work sites or from site-to-site: Rarely Works primarily out of the office; 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 confidential information that must be protected at all times. All employees must comply with HIPAA and company privacy policies and information security guidelines. Furthermore, it is every employees responsibility to comply with the companys Code of Business Conduct and applicable laws, rules, and regulations. Pay Range
Minimum: $170,000.00 Maximum: $342,274.00 Base pay is determined by a variety of factors including qualifications, experience, and contributions, as well as internal equity, market, and business considerations. The salary range does not reflect geographic differentials that may apply by location. Highmark Health and its affiliates are an Equal Opportunity Employer. EEO is The Law. Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity. We value accessibility; for accommodations contact HR Services Online. Req ID: J254551 #J-18808-Ljbffr