Medical Director, Medical Management

Apply for Medical Director Medical Management | Careers at Highmark Health Skip to main content Careers Working here Our Companies Career Areas Early CareersInterns Talent Community Team Member Stories Veterans Explore Jobs Clinical ServicesMedical Director Medical Management Explore our jobs Medical Director Medical Management Apply Open in new tab iconPA Working at Home - PennsylvaniaCompany Highmark Inc.Job Description JOB SUMMARYThis job as part of a physician team ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA URAC CMS DOH and DOL regulations at all times. In addition to utilization review the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases particularly high-risk cases through the team structure. Additionally the incumbent may be assigned special projects to help support and improve the care of our membersESSENTIAL RESPONSIBILITIESConduct 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 all while adhering to required compliance standards NCQA URAC CMS DOH and DOL regulations etc.. 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 multidisciplinary team on cases that require physician expertise.Participate in protocol and guidelines development to ensure consistency in the review process.Actively manage projects andor participate on project teams that require a physician subject matter expert.Other duties as assigned. EDUCATIONRequiredMedical Doctor MD or Doctor of Osteopathic Medicine DOSubstitutionsNonePreferredMasters Degree in Business AdministrationManagement or Public HealthEXPERIENCERequired5 years in Clinical Direct Patient care hospital outpatient or private practicePreferred1 year in Medical Management in a Health Insurance Plan strong knowledge of managed care industryLICENSES AND CERTIFICATIONRequiredMedical Doctor or Doctor of Osteopathic Medicine DOAwarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying BoardsActive medical state licensure required. Additional specific state licensures may be required based on business need.PreferredNoneSKILLSCritical ThinkingCase ManagementCustomer ServiceOral & Written Communication SkillsCollaborationListeningTelephone SkillsGeneral Computer SkillsClinical SoftwareManaged CareLanguage Other than EnglishNoneTravel Required0 - 25PHYSICAL MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-BasedTeaches trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling productsservices sales employeesNeverPhysical work site requiredNoLifting up to 10 poundsConstantlyLifting 10 to 25 poundsRarelyLifting 25 to 50 poundsRarelyDisclaimer 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. In connection with this all employees must comply with both the Health Insurance Portability Accountability Act of 1996 HIPAA as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Companys Handbook of Privacy Policies and Practices and Information Security Policy.Furthermore it is every employees responsibility to comply with the companys Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws rules and regulations as well as company policies and training requirements. Pay Range Minimum170000.00Pay Range Maximum352500.00Base pay is determined by a variety of factors including a candidates 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.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.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 HRServiceshighmarkhealth.orgCalifornia Consumer Privacy Act Employees Contractors and Applicants Notice Apply Job DetailsJob categoryClinical ServicesPosition TypeFull TimePosted2025-11-20T202304.8616060000LocationsPA Working at Home - PennsylvaniaLine of BusinessEntityRecruiterHiring ManagerExperience LevelReq IDJ272806 Share Facebook X LinkedIn Whatsapp Email Copy URL Apply Open in new tab iconArrow left iconTwitter iconFacebook iconLinkedin iconInstagram iconYoutube iconGlassdoor icon Featured Links Competitively Sensitive Information Cyber Security Notice at Collection E-Verify English E-Verify - Employee Rights and Responsibilities Data Protection Sitemap Terms of Service Do Not SellShare E-Verify Spanish Digital Privacy Policy Highmark Health is an independent licensee of the Blue Cross Blue Shield Association. 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. 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 HRServiceshighmarkhealth.org. © 2025 Highmark Health. All Rights Reserved.