15,291 Medical Services Director jobs in the United States

This job carries with it the obligation to uphold the Mission of Lone Star College (LSC) in carrying out the duties of the position. A commitment to positive interpersonal behaviors, professional communication, integrity, leadership, stewardship, respect and accountability to LSC students and employees is essential.

Cultural Beliefs

• One LSC
• Student Focused
• Own It
• Foster Belonging
• Cultivate Community
• Choose Learning

The Chronicle of Higher Education's "Great Colleges to Work For" is designed to recognize colleges that have been successful in creating great workplaces and to further research and understanding of the factors, dynamics and influences that have the most impact on organizational culture at higher education institutions.

Lone Star College has been recognized in multiple categories.

As faculty members of Lone Star College, we strive to create a nation of world citizenry in our students. In that pursuit, we model ways of thinking and being that incorporate diversity, equality, and equity. Our culture, then, requires the possession of transcendent qualities that, while immeasurable, are evident in global citizens. We are compassionate with our students, colleagues, and ourselves. We are innovative in the pursuit of learning. Ultimately, we create a culture where learning thrives, people are safe, and we mirror the qualities of world citizenry.

Lone Star College faculty are dedicated to four qualities of excellence:

• Student Invested
• Content Expert
• Pedagogically Excellent
• Institutionally Dedicated

Lone Star College-Magnolia Center:

The Lone Star College-Magnolia Center is a state-of-the-art, full-service satellite center that serves as a dynamic hub for higher education in Southwest Montgomery and Southeast Waller counties.

Lone Star College System offers high-quality, low-cost academic transfer and career training opportunities to 90,000 students each semester. The college system has eight main colleges, eight centers, eight Workforce Centers of Excellence and Lone Star Corporate College.

LSC-Magnolia Center offers students the opportunity to complete associate degrees for university transfer and pursue workforce certifications in HVAC and Emergency Medical Services (EMS).

Location address is 1280 Escondido Dr, Magnolia, TX 77354.

PURPOSE AND SCOPE:

It is the responsibility of the teaching faculty to provide the learning activities and support that will lead to the achievement of the course objectives and contribute to the educational environment of the college and the community. The faculty member's role encompasses the general areas of learning facilitation, professional development, and institutional service. Primary responsibilities are to plan, develop and teach courses within the curriculum in a manner that facilitates student learning.

ESSENTIAL JOB FUNCTIONS:

1. Teaches courses in Emergency Medical Services Professions at a variety of times and locations in response to institutional needs
2. Makes continuous efforts to improve the quality of instruction by reviewing and utilizing innovative methodologies, techniques, and delivery methods
3. Develops and uses a syllabus for each course or laboratory within college and departmental guidelines
4. Plans, develops and uses a variety of teaching methods and materials that assist students in meeting course objectives and which are appropriate for students with differing educational and experiential backgrounds and learning styles
5. Evaluates students to measure their progress toward achievement of stated course objectives and informs them in a timely manner of their progress in the course
6. Submits required college reports and forms
7. Reviews, evaluates, and recommends student learning materials
8. Maintains professional relationships with students, colleagues and the community
9. Provides access to students through posted office hours, electronic communication and other appropriate methods
10. Responsible for professional development and institutional service as determined in consultation with the Dean
11. Responsible for other reasonable related duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES:

• Mastery of course content
• Demonstrated leadership skills; style that emphasizes collaboration, teamwork, and facilitation
• Excellent oral and written communication skills and interpersonal skills
• Ability to appreciate alternative viewpoints; ability to work effectively with a wide variety of people
• Commitment to academic excellence, exceptional service and providing a dynamic climate for life-long learning
• Demonstrated ability to develop and implement instructional approaches such as service learning/civic engagement, learning communities, and the effective use of technology
• Ability to use effective strategies to engage students in their learning

PHYSICAL ABILITIES:

The work requires considerable and strenuous physical exertion, such as frequent climbing of tall ladders, lifting heavy objects over 50 pounds, crouching or crawling in restricted areas, and defending oneself or others against physical attack.

WORK SCHEDULE AND CONDITIONS:

• Equipment used includes, PC workstation running on a LAN in a Microsoft Windows environment, calculator, phone and other general office equipment, and any specialized equipment standard within the discipline/industry
• Interface with internal and external contacts as needed to carry out the functions of the position
• Work is performed in a climate-controlled classroom and/or lab environment with exposure to safety hazards typical within the industry
• Hours will vary depending on class time; Instructors are required to meet with classes at all scheduled times and be available to students outside of class instruction

REQUIRED QUALIFICATIONS:

• Associate's degree in Emergency Medical Services (EMS) or related Field or Bachelor's degree and 3 years nonteaching work experience in the field. Must be certified or registered as a paramedic

Commensurate with education, experience and qualifications.

Your salary offer would fall in that range is determined by your related experience and education. Should you receive an offer of employment from Lone Star College, the resume submitted in the application process will be utilized to calculate your salary offer. The information outlined below will provide the Office of Human Resources everything needed to determine an accurate starting salary.

Your resume should provide a complete picture of your work experience. The resume should include the following information for each position listed:

1. Length of time (specific months and years) of employment
2. If the position was full time or part time
3. If the position was paid or unpaid
4. Level of degree completed including date earned.
5. Unofficial transcript for highest earned degree

Additionally, any certifications listed as required or preferred in the Lone Star College job description should be included in the resume submitted.

By joining our top-notch institution, you will enjoy being a part of an organization that offers a supportive, collegial work environment and excellent work/life balance. This includes a full comprehensive and competitive benefits package, wellness programs, professional development opportunities, sabbatical opportunities and more.

This position will also serve as the EMS Program Director for an additional annual stipend.

According to CAAHEP Standards, the EMS Program director must have the following:

A minimum of a bachelors degree

Documented education or experience in instructional methodology

Academic training and experience equivalent to that of a paramedic

Experience in the delivery of prehospital emergency care

Knowledge about the current versions of the National EMS Scope of Practice and National EMS Standards.

For the State of Texas, the EMS Program director must have the following:

Current Texas Licensed Paramedic

Basic Course Coordinator License (only for EMT courses)

oMust have been a certified instructor for at least two consecutive years

oHave documented not less than 120 hours of instruction for initial EMS certification

oSubmit documentation of positive evaluations as a certified instructor

Advanced Course Coordinator License (for EMT and paramedic courses)

oHave an associate degree, a bachelors degree, or an advanced degree

oHave been a certified EMS instructor for at least four consecutive years or as a basic course coordinator for two consecutive years

oHave documented not less than 2440 hours of instruction for initial EMS certification

oSubmit documentation of positive evaluations as a certified instructor according to CAAHEP Standards, the EMS Program director must have the following:

Go to the Job Search page, click on `My Activities at the top of the page. Under My Cover Letters and Attachments you will click on `Add Attachment. Please be sure to put the Job ID# in the title once you name your file for cover letters only, unless you attached your cover letter with your resume.

If you are applying for an Instructional position (i.e. Faculty, Adjunct Faculty, Instructor), please ensure you include the following to be considered: Resume/CV, Cover Letter, Teaching Philosophy, and unofficial transcripts.

You must limit your file name for any attachment to 40 characters or less.

ALL APPLICANTS MUST APPLY ONLINE ONLY

We will not accept application material received via fax, email, mail, or hand delivered.

Postings for part-time and adjunct positions are active for the academic year. By selecting the option to receive notifications on your profile, you will begin receiving electronic communication regarding new opportunities with Lone Star College (LSC).

If selected for an interview, a recruiter will contact you by phone, or email to schedule an interview.

Lone Star College participates in the E-Verify program, under which Lone Star College provides the federal government with information from each new employee's Form I-9 to confirm that the employee is authorized to work in the United States.

More information on the E-Verify program is available at

Lone Star College is an EEO Employer. All positions are subject to a criminal background check.

Overview:

Commonwealth Senior Living is seeking early career applicants for our Fall 2025  Internship Program . The healthcare administration intern will be exposed to all areas of operations at the community level and will have an opportunity to interact 1:1 with each department leader. This internship prepares candidates to manage an assisted living facility, working side by side with the administrator in a long-term care setting while learning the ins and outs of each department and receiving mentorship from department heads and experienced leaders in the industry.

Commonwealth Senior Living is a recognized leader in senior living, employing around 2,000 associates, and is a five consecutive year recipient of the Great Place to Work certification! We provide numerous opportunities for career growth by investing in creating a culture of great leaders. Some of our signature programs include The Developing Leaders Program, The Center of Excellence, and the Executive Director in Training Program. 

This is a paid internship and candidate must be available to work on site in Manassas, VA.

Hours: 20-40 hours week.

Pay Rate: $12/hour

Here is what to expect during your 10-week rotation:

• You will rotate and work 1:1 with each department including front office and executive administration, resident care, programming, dining, sales, and maintenance.
• Meet weekly with different members from Senior Leadership in our Home Office to gain an understanding and a high-level overview of each department.
• Participate in meetings with department leaders and staff to further understand operations management and all aspects involved in creating a home like atmosphere for our residents
• Assist with various operational projects as directed by the Executive Director and Business Office Manager
• Develop relationships with various personnel to understand organizational structure

Responsibilities :

• Business Office:   Gain knowledge of general HR policies, procedures, FMLA, and the Worker's Compensation process. Develop recruitment strategies and interviewing techniques. Organize and assist with the facilitation of Jump Start and other employee trainings.
• Resident Care: In keeping with our community theme, Commonwealth Senior Living refers to our individuals in the communities as residents. You will work with the Resident Care Director to help organize charts and paperwork. Assist with archiving records, disposal of expired medicines if applicable, and reaching out to families to schedule care conferences.
• Resident Programs: Assist with outings and events. Offer any unique talents you might have to coordinate resident programs.
• Sales: You will shadow the Sales Director to gain an understanding of the customer journey experience (relationship building through phone calls, community experiences, etc.).
• Dining Services: Develop an understanding of the menu creation process (how to order, prepare, serve, post service), and gain an understanding of the financials of PRD’s and budgeting.
• Maintenance & Capital Programs: Understanding emergency systems and their functions. Develop knowledge in housekeeping standards, MEPs (Mechanical, Electrical and Plumbing) processes, and Operational Maintenance budget.

Qualifications:

• Seeking a degree in Healthcare Administration, Human Services, Business Administration, or related field.
• Must possess a spirit of cooperation and enthusiasm.
• Must maintain confidentiality.
• Must use tact and courtesy in dealing with staff, residents, their families, and visitors.
• Demonstrate a warm, outgoing, and compassionate personality.
• Demonstrated integrity, maturity, and leadership skills. 
• Able to live out Commonwealth Senior Living’s Noble selling purpose – “We improve the lives of seniors, their families, and each other.”

Commonwealth Senior Living is a recognized leader in senior living, employing around 2,000 associates, and is a five consecutive year recipient of the Great Place to Work certification!

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 concise 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.

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 in a health insurance plan; strong knowledge of managed care industry

Licenses and Certification:

• Required: Medical Doctor or Doctor of Osteopathic Medicine (DO), awarded board certification at least once in 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 required based on business need.
• Preferred: None

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

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 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: $352,500.00

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 any category protected by applicable federal, state, or local law. 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 HR Services Online at

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 concise 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.

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 in a Health Insurance Plan; strong knowledge of managed care industry

Licenses and Certification:

• Required: Medical Doctor or Doctor of Osteopathic Medicine (DO), Awarded Board Certification at least once in 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 required based on business need.
• Preferred: None

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: $352,500.00

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 any category protected by applicable federal, state, or local law. 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 HR Services Online at

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 concise 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

• 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 in a Health Insurance Plan; strong knowledge of managed care industry

LICENSES AND CERTIFICATION

Required

• Medical Doctor or Doctor of Osteopathic Medicine (DO)

• Awarded Board Certification at least once in 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 required based on business need.

Preferred

• None

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 Companys Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employees responsibility to comply with the companys 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:

$352,500.00

Base pay is determined by a variety of factors including a candidates 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 any category protected by applicable federal, state, or local law.

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 the email below.

For accommodation requests, please contact HR Services Online at

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J267780

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 concise 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: 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 in a Health Insurance Plan; strong knowledge of managed care industry

Licenses and Certification:

• Required: Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification at least once in 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 required based on business need.
• Preferred: None

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

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: $352,500.00 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.

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 concise 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.

Required: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Substitutions: None

Preferred: Master's Degree in Business Administration/Management or Public Health

Required: 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)

Preferred: 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

Required: Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification at least once in 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 required based on business need.

Preferred: None

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: $352,500.00 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 any category protected by applicable federal, state, or local law. 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 the email below. For accommodation requests, please contact HR Services Online at California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J267780

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 concise 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.

Required: Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Substitutions: None

Preferred: Master's Degree in Business Administration/Management or Public Health

Required: 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)

Preferred: 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

Required: Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification at least once in 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 required based on business need.

Preferred: None

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: $352,500.00 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 any category protected by applicable federal, state, or local law. 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 the email below. For accommodation requests, please contact HR Services Online at California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J267780