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Chief Medical Officer

2 months ago

Helena, Montana, United States Highmark Health Full time


Highmark Health Chief Medical Officer
This position is integral to a collaborative physician team, ensuring that utilization management tasks are executed in alignment with the highest and most up-to-date clinical benchmarks.

The role involves the assessment of escalated cases through electronic means, utilizing Medical Policy criteria to ascertain the medical necessity and suitability of the requested treatments or services.

In certain instances, telephonic peer discussions may be necessary. The individual in this role will guarantee adherence to NCQA, URAC, CMS, DOH, and DOL regulations consistently.

Beyond utilization review, the Chief Medical Officer will engage as a physician member of the multidisciplinary team focused on case and disease management.

They will provide guidance to the multidisciplinary team on cases, especially those that are high-risk, through the established team framework. Additionally, the role may involve special projects aimed at enhancing the care provided to our members.

KEY RESPONSIBILITIES

Conduct electronic evaluations of escalated cases against medical policy criteria, which may involve telephonic peer discussions, to determine medical necessity and appropriateness.

Complete initial case determinations, reviews of appeals and grievances, and other assessments as required.

Draft clear and concise rationales for member and provider determination notifications while complying with required standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.).

Ensure that all facets of the medical management process align with community care standards.
Participate as a member of the CMDM multidisciplinary team. Attend team meetings and case discussions. Advise the multidisciplinary team on cases requiring physician expertise.
Engage in the development of protocols and guidelines to ensure consistency in the review process.
Actively oversee projects and/or contribute to project teams that necessitate a physician subject matter expert.
Other responsibilities as assigned.

EDUCATION
Required
Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Substitutions
None
Preferred
Master's Degree in Business Administration/Management or Public Health

EXPERIENCE
Required
5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Preferred
1 year in Medical Management within a Health Insurance Plan; strong understanding of the managed care sector

LICENSES AND CERTIFICATION
Required
Medical Doctor or Doctor of Osteopathic Medicine (DO)
Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Active medical state licensure required. Additional specific state licensure(s) may be necessary based on business needs.
Preferred
None

SKILLS
Critical Thinking
Case Management
Customer Service
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

Physical work site required:
No

Lifting:
up to 10 pounds: Constantly
Lifting: 10 to 25 pounds: Rarely
Lifting: 25 to 50 pounds: Rarely

Disclaimer:

This 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.