Highmark Health - Montpelier, VT
posted 2 months ago
Full-time - Senior
Montpelier, VT
Insurance Carriers and Related Activities
About the position
The Medical Director at Highmark Health is responsible for overseeing utilization management and ensuring compliance with clinical standards and regulations. This role involves reviewing escalated cases, participating in multidisciplinary teams, and advising on high-risk cases. The Medical Director also engages in protocol development and may lead special projects to enhance member care.
Responsibilities
- Conduct electronic review of escalated cases against medical policy criteria, including telephonic peer discussions to determine medical necessity and appropriateness.
- Complete initial determination of cases, review appeals and grievances, and compose rationales for member and provider notifications while adhering to compliance standards.
- Participate as a member of the CMDM multidisciplinary team, attending huddles and grand rounds, and advising on cases requiring physician expertise.
- Participate in protocol and guidelines development to ensure consistency in the review process.
- Actively manage projects or participate on project teams requiring a physician subject matter expert.
- Perform other duties as assigned.
Requirements
- Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) required.
- 5 years of experience in Clinical, Direct Patient care (hospital, outpatient, or private practice) required.
- Board Certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards required.
- Active medical state licensure required.
Nice-to-haves
- Master's Degree in Business Administration/Management or Public Health preferred.
- 1 year of experience in Medical Management in a Health Insurance Plan preferred.
Benefits
- Health insurance coverage
- Dental insurance coverage
- Life insurance coverage
- 401k retirement savings plan
- Paid holidays
- Paid time off (PTO)
