Overview
Highmark Inc. is seeking a physician to join a team responsible for utilization management and case/disease management in accordance with current clinical standards. The incumbent reviews escalated cases electronically using Medical Policy criteria to evaluate medical necessity and appropriateness of requested treatments. Telephonic peer-to-peer discussions may be required. The role ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and contributes as a physician member of the multidisciplinary team, advising on high-risk cases. The incumbent may also be assigned special projects to support and improve member care.
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 determinations, reviews of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determinations, ensuring compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Ensure 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 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
- 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 the 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 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
None
Travel
0% - 25%
Physical, Mental Demands and Working Conditions
Office-Based
Teaches / trains others regularly
Occasionally travel regularly from the office to various work sites or site-to-site
Works primarily out-of-the-office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: This job description indicates the general nature and essential duties and responsibilities. It may not contain a comprehensive inventory of all duties and qualifications.
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 and must comply with HIPAA, privacy policies, and data security guidelines. Employees must comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations.
Pay
Minimum: $170,000.00
Maximum: $352,500.00
Base pay is determined by qualifications, experience, expected contributions, internal peer equity, market conditions, and business considerations. Salaries may vary by location.
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