Highmark Inc.
Health Insurance
MedicalDirector
“Medical Director at Highmark Inc.. Skills: Utilization Management, Medical Policy, Medical Necessity, Case Management, Disease Management. Reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service.. Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness.”
What You'll Achieve.
Ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.; Ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times.
Industry & Context.
Critical Thinking
Lifting: up to 10 pounds Constantly, Lifting: 10 to 25 pounds Rarely, Lifting: 25 to 50 pounds Rarely
What They're Looking For.
Must Have
Medical Doctor (MD) 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, 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Nice to Have
Master's Degree in Business Administration/Management or Public Health, 1 year in Medical Management in a Health Insurance knowledge of managed care industry
What You'll Do.
Reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service.
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 all while adhering to required compliance standards (NCQA
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 and/or participate on project teams that require a physician subject matter expert.
How You'll Work.
Team & Collaboration
Participates as the physician member of the multidisciplinary team for case and disease management.; Advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure.; Participate as a member of the CMDM multidisciplinary team.; Attend huddles and grand rounds.; Advise multidisciplinary team on cases that require physician expertise.; Participate on project teams that require a physician subject matter expert.
Communication Scope
Oral & Written Communication Skills; Telephone Skills
Process & Methodology
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
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