Medical Director, Medical Policy - Remote

Overview

The Medical Director, Medical Policy role at Highmark Inc. involves overseeing the creation and management of medical policies for commercial and Medicare Advantage programs, ensuring compliance with regulatory standards and providing clinical expertise.

In Short

• Support the Medical Policy team with expertise and experience.
• Manage full-cycle ownership of medical policies.
• Write clinical criteria based on research.
• Engage with clinical and non-clinical team members.
• Ensure compliance with NCQA and CMS requirements.
• Address escalated inquiries from partners.
• Conduct peer reviews as part of quality assurance.
• Train and mentor new staff members.
• Collaborate with Utilization Management for policy improvements.
• Participate in work-groups and sub-committees.

Requirements

• 5 years of active medical practice required.
• 3 years of medical policy experience required.
• 1 year of medical coding experience preferred.
• Doctor of Medicine or Doctor of Osteopathic Medicine required.
• Board certification in a recognized specialty required.
• Active medical state licensure required.
• Strong critical thinking skills.
• Excellent oral and written communication skills.
• Proficiency in general computer skills, including Excel.
• Experience with clinical software and MS Office.

Benefits

• Competitive salary range from $170,000 to $352,500.
• Comprehensive health benefits.
• Opportunities for professional development.
• Flexible working arrangements.
• Supportive work environment.
• Engagement in innovative healthcare solutions.
• Collaboration with a diverse team.
• Access to cutting-edge healthcare technology.
• Participation in a mission-driven organization.
• Less than 25% travel required.