Medical Director, Medical Management
Not Disclosed•Full-TimeOn-site
location_onBeacon Street Mall, Beacon Hill, Boston, Suffolk County, Massachusetts, 02108, United States
About the Role
As a physician within a multidisciplinary team at Highmark Inc., you will serve as a critical guardian of clinical standards in utilization management. This role exists to ensure that every escalated case is evaluated with the highest level of medical expertise, balancing the needs of members with the rigorous requirements of the managed care industry.
You will act as the clinical voice on the Case and Disease Management (CMDM) team, advising on complex, high-risk cases and contributing to the development of protocols that ensure consistency in care. Your work directly impacts the quality of care our members receive by reviewing escalated cases against medical policy criteria, determining medical necessity, and composing clear rationales for providers and members. Whether through electronic reviews or telephonic peer-to-peer discussions, you will navigate the intersection of clinical judgment and regulatory compliance to support the health and well-being of our community.
Compliance and Culture
Highmark Health is committed to the highest ethical and legal standards. In this role, you will ensure strict adherence to NCQA, URAC, CMS, DOH, and DOL regulations while protecting confidential member information in compliance with HIPAA and our internal data security policies. We foster a culture of collaboration and continuous improvement, where your expertise helps shape the future of our care delivery models.
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.
Application Process
Interested candidates should submit their application through the Highmark careers portal. For accommodation requests or assistance with the application process, please contact HR Services Online at HRServices@highmarkhealth.org.
Work location
Work model: On-site
Beacon Street Mall, Beacon Hill, Boston, Suffolk County, Massachusetts, 02108, United States
Boston, Massachusetts
Key Responsibilities
Similar Job Opportunities
Skills, education and keywords
Skills: Case Management, Clinical Software, Managed Care.
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 Beacon Street Mall, Beacon Hill, Boston, Suffolk County, Massachusetts, 02108, United States. This is a on-site role.