Medical Director, Clinical Services
Company: Highmark Health
Location: Santa Fe
Posted on: May 25, 2023
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Job Description:
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 concises 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
Substitutions
Preferred
EXPERIENCE
Required
5 - 7 years in Clinical, Direct Patient care (hospital, outpatient,
or private practice)
1 - 3 years in Medical Management in a Health Insurance Plan;
strong knowledge of managed care industry
Preferred
LICENSES AND CERTIFICATION
Required
Medical Doctor or Doctor of Osteopathic Medicine (DO), with an
active, unrestricted license to practice in any U.S. state
Awarded Board Certification at least once in specialty recognized
by the American Board of Medical Specialties or the American
Osteopathic Association Specialty Certifying Boards
Preferred
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
Disclaimer: 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.
Compliance Requirement : This job adheres to the ethical and legal
standards and behavioral expectations as set forth in the code of
business conduct and company policies.
As a component of job responsibilities, employees may have access
to covered information, cardholder data, or other confidential
customer information that must be protected at all times. In
connection with this, all employees must comply with both the
Health Insurance Portability Accountability Act of 1996 (HIPAA) as
described in the Notice of Privacy Practices and Privacy Policies
and Procedures as well as all data security guidelines established
within the Company's Handbook of Privacy Policies and Practices and
Information Security Policy.
Furthermore, it is every employee's responsibility to comply with
the company's Code of Business Conduct. This includes but is not
limited to adherence to applicable federal and state laws, rules,
and regulations as well as company policies and training
requirements.
Pay Range Minimum:
$170,000.00
Pay Range Maximum:
$322,900.00
Base pay is determined by a variety of factors including a
candidate's qualifications, experience, and expected contributions,
as well as internal peer equity, market, and business
considerations. The displayed salary range does not reflect any
geographic differential Highmark may apply for certain locations
based upon comparative markets.
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, age, 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, age, religion, sex, national origin, sexual
orientation/gender identity, protected veteran status or
disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected
Veterans/Disabled/Sexual Orientation/Gender Identity (
https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf
)
We endeavor to make this site accessible to any and all users. If
you would like to contact us regarding the accessibility of our
website or need assistance completing the application process,
please contact number below.
For accommodation requests, please contact HR Services Online at
HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and
Applicants Notice
Req ID: J212252
Keywords: Highmark Health, Santa Fe , Medical Director, Clinical Services, Healthcare , Santa Fe, New Mexico
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