Job ID: J113233
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 29, 2018
This job leads a physician team and ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent oversees a team of Associate Medical Directors and Medical Directors who are responsible for reviewing escalated cases electronically and using Medical Policy criteria sets, evaluating 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 physician team must ensure compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times, and the Senior Medical Director will be responsible for ensuring that those measures are met. In addition to utilization review, the physician teams participate as physician members of CMDM multidisciplinary teams for case review. They will advise the multidisciplinary team on cases, particularly high risk cases, through the team structure. Additionally, the physicians may be assigned special projects to help support and improve the care of our members. As the leader of these physicians, the Senior Medical Director will manage performance accordingly, delegate projects, and determine which team members will participate in which multidisciplinary teams. Also, as a physician leader, the incumbent consults other departments across the Highmark Health Plan and Allegheny Health Network as needed. They may serve on committees or project teams as a subject matter expert, depending on specialty and prior experience.
LICENSES AND CERTIFICATIONS
The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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