About Highmark Health
Highmark Health is a national, blended health organization that includes one of America's largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health's 35,000 employees serve millions of customers nationwide through the nonprofit organization's affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions, and HM Home & Community Services. Highmark Health's businesses proudly serve a broad spectrum of health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.
About the Role
We are seeking an experienced Part-Time Weekend Medical Director to join our team in a remote capacity. As a key member of our physician team, you will ensure that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. Your expertise will be essential in reviewing escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment or service. You will also participate as the physician member of the multidisciplinary team for case and disease management, advising the team on cases, particularly high-risk cases, through the team structure.
Key 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, attending huddles and grand rounds, and advising the 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.
Essential Qualifications
To be successful in this role, you will need to possess the following essential qualifications:
- Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree.
- At least 5 years of experience in clinical, direct patient care (hospital, outpatient, or private practice).
- Board Certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.
- Active medical state licensure required, with additional specific state licensure(s) may be required based on business need.
Preferred Qualifications
In addition to the essential qualifications, we prefer candidates with the following:
- Master's Degree in Business Administration/Management or Public Health.
- 1 year of experience in Medical Management in a Health Insurance Plan, with strong knowledge of the managed care industry.
Skills and Competencies
To excel in this role, you will need to possess the following skills and competencies:
- Critical thinking and problem-solving skills.
- Excellent communication and interpersonal skills.
- Ability to work independently and as part of a team.
- Strong analytical and technical skills, with proficiency in clinical software and managed care systems.
- Ability to adapt to changing priorities and deadlines.
Career Growth Opportunities and Learning Benefits
At Highmark Health, we are committed to the growth and development of our employees. As a Part-Time Weekend Medical Director, you will have opportunities to:
- Develop your clinical and leadership skills through training and professional development programs.
- Participate in project teams and contribute to the development of new policies and procedures.
- Collaborate with multidisciplinary teams to improve patient outcomes and advance population health management.
- Take advantage of our tuition reimbursement program and pursue further education or certifications.
Work Environment and Company Culture
As a remote employee, you will have the flexibility to work from home and enjoy a better work-life balance. Our company culture values diversity, equity, and inclusion, and we are committed to creating a workplace that is welcoming and inclusive for all employees. We offer a range of benefits, including:
- A competitive salary and bonus structure.
- A comprehensive benefits package, including medical, dental, and vision insurance.
- A 401(k) retirement plan with company match.
- Flexible paid time off and holidays.
- A range of employee recognition and reward programs.
Compensation and Benefits
The compensation for this role is benchmarked at a competitive salary, with a minimum pay range of $170,000.00 and a maximum pay range of $342,274.00. In addition to your salary, you will also receive a comprehensive benefits package, including medical, dental, and vision insurance, a 401(k) retirement plan with company match, and flexible paid time off and holidays.
How to Apply
If you are a motivated and experienced medical professional looking for a new challenge, we encourage you to apply for this role. Please submit your resume and a cover letter outlining your qualifications and experience. We look forward to hearing from you!
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