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.

The listed compensation represents the hiring range for this position. This role is also eligible for additional performance based incentives, including our Annual Incentive Plan