Job Description

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

    Required

  • Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

    • Substitutions

  • None

    • Preferred

  • Master's Degree in Business Administration/Management or Public Health

    • EXPERIENCE

    Required

  • 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)

    • Preferred

  • 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

    • LICENSES AND CERTIFICATION

    Required

  • Medical Doctor or Doctor of Osteopathic Medicine (DO)
  • Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
  • Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.

    • Preferred

  • None

    • SKILLS

  • Critical Thinking
  • Case Management
  • Customer Service
  • Oral & Written Communication Skills
  • Collaboration
  • Listening
  • Telephone Skills
  • General Computer Skills
  • Clinical Software
  • Managed Care

    • Language (Other than English)

    None 

    Travel Required

    0% - 25%

    PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

    Position Type

    Office-Based

    Teaches / trains others regularly

    Occasionally

    Travel regularly from the office to various work sites or from site-to-site

    Rarely

    Works primarily out-of-the office selling products/services (sales employees)

    Never

    Physical work site required 

    No

    Lifting: up to 10 pounds

    Constantly

    Lifting: 10 to 25 pounds

    Rarely

    Lifting: 25 to 50 pounds

    Rarely

    Pay Range Minimum:

    $170,000.00

    Pay Range Maximum:

    $352,500.00

    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.

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