Senior Medical Director Utilization Management Oncology

Senior Medical Director Utilization Management Oncology

Work Location: REMOTE (work from home)

California         Nevada               Arizona               Oregon                Florida

As a Senior Medical Director, Utilization Management, you will report directly to the Chief Clinical Officer and support key C-suite clinical initiatives. This is a leadership role with responsibility for providing medical and strategic oversight of utilization management while leading and developing a clinical Utilization Management team. You will guide the evaluation of the clinical necessity and appropriateness of oncology treatments, ensuring cost-effective, evidence-based care without compromising patient outcomes, while partnering closely with executive, clinical, and operational leaders across the organization.

 Key Responsibilities:

• Provide strategic and clinical leadership to the Utilization Management team, fostering high performance, accountability, and consistent application of evidence-based oncology standards.
• Build trusted relationships with the Utilization Management team and TOI and affiliated physicians to drive alignment on clinical guidelines, utilization decisions, and patient focused care.
• Coach and educate the Utilization Management team and physicians on oncology utilization standards, fostering shared accountability for quality, cost effective patient care.
• Development of strategy development to support scalable growth across TOI network.
• Conduct medical reviews of hematology and oncology treatment plans to determine medical necessity, appropriateness, and alignment with value-based clinical guidelines and evidence-based practices.
• Evaluate clinical data and collaborate with healthcare providers to ensure optimal utilization of resources for oncology patients.
• Make independent clinical decisions on the appropriateness of treatments, imaging, and interventions based on established medical standards.
• Provide expert guidance and recommendations on appropriate oncology treatments while considering cost-effectiveness and patient care quality.
• Liaise with providers, insurance companies, and patients to clarify and discuss treatment options and coverage.
• Ensure compliance with organizational policies, regulatory standards, and payer requirements in all clinical decisions.
• Participate in the development and continuous improvement of utilization management protocols and criteria specific to oncology.
• Review and assess the appropriateness of ongoing cancer treatment plans, ensuring that they align with evidence-based medicine and clinical best practices.

Qualifications:

• Medical degree (MD or DO)
• Board Certification in Oncology.
• Minimum of 5 years of clinical experience in oncology.
• 3+ years of Utilization Management leadership experience
• Proven expertise in Utilization Management or experience with reviewing clinical appropriateness of treatment plans.
• Strong understanding of oncology-specific treatment protocols, guidelines, and reimbursement policies.
• Excellent analytical skills and the ability to evaluate complex clinical data.
• Ability to work independently and make evidence-based decisions in a collaborative, multidisciplinary setting.
• Excellent communication skills to engage effectively with healthcare providers, payers, and patients.