Highmark Health
JOB SUMMARY
This role supports the Medical Policy team by bringing medical director level expertise, experience and knowledge to the team. The incumbent supports the full‑cycle ownership of commercial and Medicare Advantage medical policies, both developed internally and by vendors. Responsibilities include writing clinical criteria based on research, engaging clinical and non‑clinical team members for operational guidelines, and ensuring all existing medical policies are in accordance with NCQA and/or CMS requirements. The role may address escalated inquiries, conduct peer reviews as part of the quality review process, participate in various work‑groups and sub‑committees, train and orient new staff, and serve as a liaison between other departments and vendors as required.
ESSENTIAL RESPONSIBILITIES
Full‑cycle ownership of commercial and Medicare Advantage medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees for internally developed and vendor‑owned policies. Engage other departments, team members, strategic partners, and vendors to assist with research.
Provide clinical guidance to non‑clinical team members, including those who own Medicare Advantage policy updates and those who support the commercial policy team.
Address escalated policy inquiries that require clinical expertise, including updating or revising existing medical policies.
Partner with Utilization Management and other operational teams to identify opportunities within medical policy.
Discover and cultivate innovative opportunities that drive significant improvements in healthcare quality and efficiency.
Other duties as assigned or requested.
EXPERIENCE Required
5 years of active medical practice.
3 years of medical policy experience.
Preferred
1 year of medical coding experience.
SKILLS
Critical Thinking
Oral and Written Communication
Listening
Telephone Skills
General Computer Skills, including Excel
Clinical Software
Email Software (Outlook) and Teams
MS Word
Managed Care
EDUCATION Required
Doctor of Medicine or Doctor of Osteopathic Medicine.
Substitutions
None
LICENSES OR CERTIFICATIONS Required
Medical Doctor or Doctor of Osteopathic Medicine (DO), board certified in an American Board of Medical Specialties or Bureau of Osteopathic, specialists recognized specialty credentialed in a Highmark network.
Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.
Preferred
None
Language (Other than English)
None
Travel Required
Less than 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type
Office‑Based or Remote Position.
Physical Work Site Required
Never
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. Employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with HIPAA as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. All employees must comply with the company’s Code of Business Conduct, applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum $170,000.00
Pay Range Maximum $352,500.00
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.
EEO Statement 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 any category protected by applicable federal, state, or local law.
Accessibility 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 email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org. California Consumer Privacy Act Employees, Contractors, and Applicants Notice.
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ESSENTIAL RESPONSIBILITIES
Full‑cycle ownership of commercial and Medicare Advantage medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees for internally developed and vendor‑owned policies. Engage other departments, team members, strategic partners, and vendors to assist with research.
Provide clinical guidance to non‑clinical team members, including those who own Medicare Advantage policy updates and those who support the commercial policy team.
Address escalated policy inquiries that require clinical expertise, including updating or revising existing medical policies.
Partner with Utilization Management and other operational teams to identify opportunities within medical policy.
Discover and cultivate innovative opportunities that drive significant improvements in healthcare quality and efficiency.
Other duties as assigned or requested.
EXPERIENCE Required
5 years of active medical practice.
3 years of medical policy experience.
Preferred
1 year of medical coding experience.
SKILLS
Critical Thinking
Oral and Written Communication
Listening
Telephone Skills
General Computer Skills, including Excel
Clinical Software
Email Software (Outlook) and Teams
MS Word
Managed Care
EDUCATION Required
Doctor of Medicine or Doctor of Osteopathic Medicine.
Substitutions
None
LICENSES OR CERTIFICATIONS Required
Medical Doctor or Doctor of Osteopathic Medicine (DO), board certified in an American Board of Medical Specialties or Bureau of Osteopathic, specialists recognized specialty credentialed in a Highmark network.
Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.
Preferred
None
Language (Other than English)
None
Travel Required
Less than 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type
Office‑Based or Remote Position.
Physical Work Site Required
Never
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. Employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with HIPAA as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. All employees must comply with the company’s Code of Business Conduct, applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum $170,000.00
Pay Range Maximum $352,500.00
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.
EEO Statement 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 any category protected by applicable federal, state, or local law.
Accessibility 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 email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org. California Consumer Privacy Act Employees, Contractors, and Applicants Notice.
#J-18808-Ljbffr