Medical Director, Medical Management
Not Disclosed•Full-TimeOn-site
location_on948, Spencer Street, Makiki Kai, Honolulu, Honolulu County, Hawaii, 96822, United States
About the Team
Highmark Inc. is dedicated to improving the health and well-being of the communities it serves. This role operates within a physician team focused on ensuring that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The team works collaboratively to support the care of members through rigorous review processes and multidisciplinary case management.
About the Role
As a physician member of this team, you will ensure that medical necessity and appropriateness of requested treatments are evaluated using Medical Policy criteria sets. Your work involves reviewing escalated cases electronically and engaging in telephonic peer-to-peer discussions when necessary. Beyond individual case reviews, you will serve as a key advisor to a multidisciplinary team for case and disease management, particularly guiding decisions on high-risk cases. You will also contribute to protocol and guideline development to maintain consistency in the review process and may lead special projects aimed at improving member care.
Hiring Process
Candidates interested in this opportunity are encouraged to apply through the official Highmark careers portal. The application process includes a review of qualifications and experience to ensure alignment with the required medical licensure and clinical background. Selected candidates will be contacted for further steps in the selection process.
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. The company endeavors to make its site accessible to all users and provides accommodations for the application process upon request. All employees are expected to adhere to the Code of Business Conduct, ethical standards, and legal requirements, including HIPAA compliance and data security guidelines.
Work location
Work model: On-site
948, Spencer Street, Makiki Kai, Honolulu, Honolulu County, Hawaii, 96822, United States
Honolulu, Hawaii
Key Responsibilities
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
In this Medical Director, Medical Management at Highmark Health role, you will 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
To qualify for the Medical Director, Medical Management at Highmark Health position, applicants should have: 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 948, Spencer Street, Makiki Kai, Honolulu, Honolulu County, Hawaii, 96822, United States. This is a on-site role.