Medical Director

Company : Highmark Inc.

Job Description

JOB SUMMARY This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.

The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required.

The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management.

They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure.

Additionally, the incumbent may be assigned special projects to help support and improve the care of our members ESSENTIAL 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 determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.)

Ensure that all aspects of the medical management process are consistent with community standards of care. Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.

Participate in protocol and guidelines 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 Require