Medical Director

Highmark Health • Cheyenne, WY • 11h ago

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This 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 members

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 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 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 (Other than English)

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)

Never

Physical work site required

Lifting: up to 10 pounds

Constantly

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. 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 Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's 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 Minimum:

$227,600.00

Pay Range Maximum:

$385,000.00

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.

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 HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J280711

Similar Jobs

Medical Director

Highmark Health • Cheyenne, WY • 11h ago

Hospital & Medical

Company : Highmark Inc. Job Description : JOB SUMMARY This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical sta...

11h ago

Go to Apply

Medical Director

Highmark Health • Cheyenne, WY • 11h ago

Hospital & Medical

11h ago

Go to Apply

Health Information Specialist I-Entry Level

Datavant • Cheyenne, WY • 1d ago

Hospital & Medical

Datavant is the data collaboration platform trusted for healthcare. Guided by our mission to make the world's health data secure, accessible and actionable, we provide critical data solutions for organizations across the...

1d ago

Go to Apply

Medical Coding Auditor

Humana • Cheyenne, WY • 1d ago

Hospital & Medical

Become a part of our caring community The Medical Coder extracts clinical information from a variety of medical records and assigns appropriate procedural terminology and medical codes (e.g., ICD-10-CM, CPT) to patient r...

1d ago

Go to Apply

Medical Coding Auditor

Humana • Cheyenne, WY • 1d ago

Hospital & Medical

Become a part of our caring community The Medical Coding Auditor reviews medical claims submitted against medical records provided to ensure correct coding guidelines are met. The Medical Coding Auditor work assignments...

1d ago

Go to Apply

Medical Director

CAI • Cheyenne, WY • 2d ago

Hospital & Medical

Medical Director Req number: R7707 Employment @type: Full time Worksite flexibility: Remote Who we are CAI is a global services firm with over 9,000 associates worldwide and a yearly revenue of $1.3 billion+. We have ove...

2d ago

Go to Apply

Director, State Public Policy for Pharmacy and Pharmacy Benefit Management

Humana • Cheyenne, WY • 2d ago

Hospital & Medical

Become a part of our caring community The Director, State Public Policy, within Humana's Government Affairs team, is responsible for shaping and executing state-level policy strategy, with a primary focus on pharmacy-rel...

2d ago

Go to Apply

Global Clinical Operations Manager

GE Aerospace • Cheyenne, WY • 2d ago

Hospital & Medical

Job Description Summary The Global Clinical Operations Manager provides international clinical leadership and operational oversight for occupational health services across multiple aerospace facilities. This role is acco...

2d ago

Go to Apply

Patient Care Technician - PCT

Fresenius Medical Care • Cheyenne, WY • 3d ago

Hospital & Medical

Training Provided PURPOSE AND SCOPE: Functions as part of the dialysis health care team in providing safe and effective dialysis therapy for patients under the direct supervision of a licensed nurse in accordance with or...

3d ago

Go to Apply

Pharmacy Support Shipping Associate

Intermountain Health • Cheyenne, WY • 4d ago

Hospital & Medical

Job Description: The Pharmacy Support Representative demonstrates proficiency in various clerical duties within a pharmacy practice site under the direction of a pharmacist, pharmacist-intern or pharmacy technician. Assi...

4d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)