Company: Highmark Inc. Job Description: POSITION SUMMARY Join our dynamic Medical Policy team as a Medical Policy Medical Director, where you will leverage your medical expertise to shape healthcare policies for our commercial and Medicare Advantage lines. In this pivotal role, you will take full ownership of the policy creation process, which involves developing clinical criteria, conducting thorough research, and collaborating with various departments and external partners to ensure that practices align with the latest standards. Your work will directly impact the quality of healthcare provided to our members. KEY RESPONSIBILITIES Lead the full-cycle development of medical policies by writing clinical criteria and overseeing clinical presentations for both internally developed and vendor policies. Engage with cross-functional teams for comprehensive policy research. Offer clinical expertise to support non-clinical team members in updating Medicare Advantage policies and aiding the commercial policy team. Handle escalated inquiries that necessitate advanced clinical knowledge, including updates to existing medical policies. Collaborate with Utilization Management and operational teams to uncover new opportunities within medical policy. Innovate solutions that drive significant enhancements in healthcare quality and efficiency. Perform additional tasks as required to support the team and the organization. QUALIFICATIONS Required: 5 years of active clinical practice experience. 3 years of experience in medical policy. Preferred: 1 year of experience in medical coding. SKILLS Strong critical thinking and analytical skills. Excellent oral and written communication abilities. Effective listening skills, alongside proficiency in general computer applications, including Excel, MS Word, and communication tools like Outlook and Teams. Familiarity with managed care principles. EDUCATION Required: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO). LICENSES OR CERTIFICATIONS Required: Board certification in a recognized specialty by an American Board of Medical Specialties or Bureau of Osteopathic Specialists; active medical state licensure is essential. Additional state licenses may be necessary based on business needs. WORKING CONDITIONS This role may be office-based or remote, with less than 25% travel required. COMPENSATION The pay range for this position is between $170,000.00 and $352,500.00, based on factors such as qualifications, experience, and contributions to the organization. Highmark Health is committed to equal opportunity and prohibits discrimination based on protected statuses. We strive to maintain an accessible environment for all users; please reach out to our HR Services for any accommodations needed during the application process. Compliance with HIPAA and other privacy regulations is required of all staff. Req ID: J273814
