Medical Director - Medical Oncology - Remote Eligible

Medical Director - Medical Oncology

Clinical Operations Medical Director

Medical Oncology

Carelon Medical Benefit Management

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.

The Clinical Operations Medical Director is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.

How You Will Make An Impact:

• Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care.
• Perform physician-level case review, following initial nurse review, of chemotherapy regimens.
• Determine medical necessity of requests using guidelines and client-specific health plan medical policy.
• Conduct peer-to-peer discussions with ordering physicians, physician assistants, and nurse practitioners to provide education regarding established guidelines and accepted standards of oncology care.
• Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application.
• Demonstrate and maintain current knowledge of new cancer treatment regimens.
• As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing.
• Participate in periodic physician team meetings.
• Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care.
• Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert.
• Perform first level provider appeals as designated by the client for adverse determinations.
• Obtain additional state licensure based upon business needs.
• Adhere to all company protocols, policies, and procedures.
• Ensures timely completion of clinical case reviews for their board certified specialty.
• Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested.
• Makes medical necessity determinations for grievance and appeals appropriate for their specialty.
• Ensures consistent use of company medical policies when making medical necessity decisions.
• Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation.

Minimum Requirements:

• Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
• Must possess an active unrestricted medical license to practice medicine or a health profession.
• Minimum of 1 year of experience with clinical case reviews for medical necessity. The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only; Cardiology, Oncology, and Interventional Pain specialties.
• Board certification in a medical specialty required.

Preferred Qualifications:

• Board Certification in Medical Oncology strongly preferred.
• 3-5 years of clinical practice experience past fellowship training is desirable.
• Demonstrated knowledge of current practice standards in oncology.