Oncology/Radiation Oncology - Clinical Operations Medical Director - Utilization Review
Medical Director -Utilization Management of Oncology Benefits
AIM Specialty Health
Location: This position has been approved to work remote, anywhere in the US with preference given to candidates located in California.
- Perform physician-level case review, following initial nurse review, of radiation therapy regimens and supportive care.
- Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging. Imaging modalities include CT, CTA, MRI, MRA, and PET.
- Determine medical necessity of requests using AIM Medical Necessity 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 AIM Specialty Health Management protocols, policies, and procedures.
- Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Board Certification by American Board of Medical Specialties in Medical Oncology or Radiation Oncology.
- 3-5 years of clinical practice experience past fellowship training is desirable.
- Demonstrated knowledge of current practice standards in oncology.
- Strong oral communication and interpersonal skills.
- Intermediate computer skills (including MS Office and Outlook), ability to learn new applications.
- Strong analytical skills.
- Ability to multi-task.
- Ability to work both independently and in a team environment.
- Ability to work in a dynamic, fast-paced environment.
MED > Licensed Physician/Doctor/Dentist
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short- and long-term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.