Medical Director, Medical Management
Not Disclosed•Full-TimeOn-site
location_on2015, West Street, Annapolis, Anne Arundel County, Maryland, 21401, United States
About the Team
At Highmark Inc., our mission is to ensure that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. As part of a physician team, you will play a critical role in evaluating the medical necessity and appropriateness of requested treatments and services. This role is integral to our multidisciplinary approach to case and disease management, ensuring that high-risk cases receive expert physician oversight.
About the Role
In this position, you will serve as a physician member of the multidisciplinary team, advising on complex cases and participating in protocol and guideline development to maintain consistency in our review processes. Your day-to-day work involves conducting electronic reviews of escalated cases against medical policy criteria, which may include engaging in telephonic peer-to-peer discussions with providers. You will be responsible for composing clear and concise rationales for member and provider determination notifications while ensuring strict adherence to community standards of care.
Beyond daily reviews, you will actively manage special projects designed to support and improve the care of our members. You will also participate in team huddles and grand rounds, contributing your clinical expertise to the broader medical management process. This role requires a balance of independent critical thinking and collaborative teamwork to navigate the complexities of managed care.
Hiring Process
Candidates interested in this opportunity are encouraged to apply through our official career portal. The application process includes a review of qualifications against our required medical licensure and board certification standards. Selected candidates will move through a structured interview process to assess clinical expertise, critical thinking skills, and cultural fit within our physician team.
Equal Opportunity & Compliance
Highmark Health and its affiliates are committed to providing a workplace free from discrimination. We prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and we do not discriminate against any individual based on categories protected by applicable federal, state, or local law.
We endeavor to make our digital platforms accessible to all users. If you require assistance completing the application process or need an accommodation, please contact HR Services Online at HRServices@highmarkhealth.org.
All employees are expected to adhere to the ethical and legal standards set forth in our Code of Business Conduct. This includes strict compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all data security guidelines established within the company's policies to protect confidential customer information.
Work location
Work model: On-site
2015, West Street, Annapolis, Anne Arundel County, Maryland, 21401, United States
Annapolis, Maryland
Key Responsibilities
- check_circleConduct electronic review of escalated cases against medical policy criteria to determine medical necessity
- check_circleCompose clear rationales for member and provider determination notifications while adhering to compliance standards
- check_circleParticipate as a physician member of the multidisciplinary team to advise on high-risk cases
- check_circleParticipate in protocol and guidelines development to ensure consistency in the review process
- check_circleManage special projects requiring physician subject matter expertise to improve member care
- check_circleReview appeals and grievances as assigned to ensure accurate case determinations
- check_circleEngage in telephonic peer-to-peer discussions to evaluate treatment appropriateness
Requirements
- verifiedMedical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
- verified5 years in Clinical, Direct Patient care
- verifiedBoard Certification recognized by ABMS or AOA
- verifiedActive medical state licensure
Nice to Have
Master's Degree in Business Administration/Management or Public Health; 1 year in Medical Management in a Health Insurance Plan with strong knowledge of the managed care industry.
