Medical Director, Medical Management
Not Disclosed•Full-TimeOn-site
location_on110, South Grand Avenue West, Hawthorne Place, Springfield, Sangamon County, Illinois, 62704, United States
About the Team
At Highmark Inc., we are dedicated to improving the health and well-being of our members. This role sits within a physician team focused on ensuring that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. As part of a multidisciplinary approach, the team works to support and improve the care of our members through collaborative case and disease management.
About the Role
This position serves as a vital link between clinical expertise and medical management. You will review escalated cases electronically using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the nature of the case, you may engage in telephonic peer-to-peer discussions to clarify clinical details.
Beyond individual case reviews, you will act as a physician member of the multidisciplinary team, advising on complex and high-risk cases during huddles and grand rounds. You will also contribute to the development of protocols and guidelines to ensure consistency in the review process. Additionally, you may be assigned special projects to support the continuous improvement of member care.
Hiring Process
Candidates interested in this opportunity are encouraged to apply through the Highmark careers portal. The application process typically includes a review of qualifications followed by interviews with the hiring team to assess clinical expertise and cultural fit. For any accommodation requests regarding the application process or website accessibility, please contact HR Services Online at HRServices@highmarkhealth.org.
Equal Opportunity & Compliance
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 are committed to making our site accessible to all users.
In this role, you will adhere to the ethical and legal standards set forth in the Code of Business Conduct. You will have access to confidential customer information and must comply with HIPAA regulations, the Notice of Privacy Practices, and all company data security guidelines. All employees are responsible for adhering to applicable federal and state laws, rules, and regulations.
Work location
Work model: On-site
110, South Grand Avenue West, Hawthorne Place, Springfield, Sangamon County, Illinois, 62704, United States
Springfield, Illinois
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 and complete initial 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.
Similar Job Opportunities
Skills, education and keywords
Skills: Case Management, Clinical Software, Managed Care, Hipaa.
Education: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) required; Master's Degree in Business Administration/Management or Public Health preferred.
Frequently asked questions about Medical Director, Medical Management at Highmark Health
What does a Medical Director, Medical Management at Highmark Health do?expand_more
A Medical Director, Medical Management at Highmark Health is responsible for the following: Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity; Compose clear rationales for member and provider determination notifications while adhering to compliance standards; Participate as a physician member of the multidisciplinary team to advise on high-risk cases; and Participate in protocol and guidelines development to ensure consistency in the review process.
What are the requirements for this Medical Director, Medical Management role?expand_more
Highmark Health is looking for candidates who meet the following requirements: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO); 5 years in Clinical, Direct Patient care; Board Certification recognized by ABMS or AOA; and Active medical state licensure.
Where is the Medical Director, Medical Management role at Highmark Health located?expand_more
Medical Director, Medical Management at Highmark Health is based in 110, South Grand Avenue West, Hawthorne Place, Springfield, Sangamon County, Illinois, 62704, United States. This is a on-site role.
Is this Medical Director, Medical Management job remote, hybrid, or on-site?expand_more
Highmark Health has listed this Medical Director, Medical Management role as on-site.
How much experience is required for this Medical Director, Medical Management role?expand_more
Medical Director, Medical Management at Highmark Health typically requires 5+ years of relevant experience at the lead level.
What skills do you need for the Medical Director, Medical Management role at Highmark Health?expand_more
Key skills for Medical Director, Medical Management at Highmark Health include Case Management; Clinical Software; Managed Care; and Hipaa.
What education is required for Medical Director, Medical Management at Highmark Health?expand_more
Educational requirements for this role: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) required; and Master's Degree in Business Administration/Management or Public Health preferred.
What category does the Medical Director, Medical Management role belong to?expand_more
Medical Director, Medical Management at Highmark Health is part of the healthcare & nursing job category on Recrutus.