Medical Director, Oncology

Brighton Health Plan Solutions, LLC•Chapel Hill, NC

5d•Hybrid

About The Position

Brighton Health Plan Solutions (BHPS) is seeking a part-time, board-certified oncologist to serve as Medical Director, Oncology. This role involves leading oncology utilization review for self-funded clients, supporting a team in making medical necessity and benefit coverage determinations for cancer care. The focus will be on medical and surgical oncology, hematology-oncology, chemotherapy and immunotherapy regimens, high-cost specialty and infusion drugs, supportive oncology therapies, and radiation oncology services. The position requires applying evidence-based criteria to determine therapy appropriateness, advising on site-of-care redirection, and serving as a clinical resource. The role can be remote or on-site in New York, and requires a passion for making cancer care more effective and affordable, along with strong clinical judgment and a collaborative style.

Requirements

Board-certified MD or DO in Medical Oncology, Hematology-Oncology, or Radiation Oncology by the American Board of Medical Specialties or the American Board of Osteopathic Specialties.
3+ years of prior clinical oncology practice, with active familiarity treating solid tumors and/or hematologic malignancies, and a demonstrated commitment to staying current on rapidly evolving oncology therapeutics.
3+ years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations, including oncology reviews.
Current, unrestricted clinical license(s); New York licensure preferred or willingness to obtain.
Excellent understanding of the utilization and case management process as applied to oncology care.
Working knowledge of NCCN Guidelines, ASCO/ASTRO/ASH guidelines, MCG oncology content, CMS NCDs/LCDs, and evidence-based standards for medical and radiation oncology.
Familiarity with oncology medical billing and coding, including HCPCS J-codes and Q-codes for chemotherapy and biologic agents, CPT codes for infusion and radiation oncology services, and ICD-10 oncology coding.
Self-motivated to stay up to date on a broad range of oncology and supportive-care services using MCG guidelines, specialty society guidelines, UpToDate, NCCN, and other resources to analyze complex cases.
Ability to communicate clearly and concisely, both verbally and in writing, including in peer-to-peer discussions with treating oncologists.
Good interpersonal and communication skills to support the team approach.
Demonstrated computer and telephonic skills.

Nice To Haves

Specialty training or fellowship beyond a first board certification in a subspecialty such as Hematology, Bone Marrow Transplant/Cellular Therapy, or a disease-specific oncology area.
Prior experience as a Medical Director or physician reviewer at a health plan, PBM, TPA, or managed care organization focused on oncology and/or specialty drug review.
Experience with oncology pathway programs, site-of-care redirection, and biosimilar preference strategies.
Familiarity with ZeOmega Jiva or a comparable medical management platform.
Experience with Workers’ Compensation oncology cases a plus.

Responsibilities

Review oncology cases and make coverage and medical necessity determinations for chemotherapy, immunotherapy, targeted therapy, hormonal therapy, and supportive care regimens using NCCN Guidelines, MCG, CMS NCDs/LCDs, specialty society guidelines, peer-reviewed literature, and proprietary medical policies.
Review high-cost specialty and infusion drug requests — including biologics, biosimilars, CAR-T cell therapies, bispecific antibodies, antibody-drug conjugates, and other oncology agents — applying appropriate step therapy, biosimilar preference, and site-of-care criteria.
Review radiation oncology requests, including IMRT, SBRT, SRS, proton beam therapy, brachytherapy, and radiopharmaceuticals, for medical necessity and appropriate clinical indication.
Review requests for diagnostic imaging, genomic and molecular testing, surgical oncology services, bone marrow and stem cell transplantation, and other oncology-adjacent services.
Support the Slate Drug Infusion PA Redirect Program and similar high-cost drug and site-of-care redirection initiatives, working closely with the medical management, pharmacy, and clinical operations teams.
Provide clinical support for all areas of Medical Affairs relating to oncology.
Advise team nurses on appropriateness of oncology care across the continuum — including infusion centers, hospitals, skilled nursing facilities, hospice, and home care — to ensure quality, cost-efficiency, and continuity of care.
Serve as the oncology medical expert for care management; review and evaluate cases with review nurses and ensure oncology care provided meets the standards for acceptable medical care.
Support nurses, social workers, and coordinators in improving their knowledge, independence, and understanding of oncology utilization and benefit determinations.
Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance oncology program performance.
Make appropriate outreach to community and academic-based treating oncologists, hematologists, and radiation oncologists wishing to discuss cases.
Conduct peer-to-peer discussions with attending physicians to review clinical information, including cases where a proposed therapy or service cannot be certified.
Communicate certification decisions to the UR nurse within appropriate time frames as guided by URAC, ERISA, or state regulations.
Review and resolve grievances related to oncology medical quality of care and actively participate in the functioning of the plan’s grievance and appeals processes.
Identify, critique, and utilize criteria and resources — including NCCN, ASCO, ASTRO, ASH, and other national, state, and professional association guidelines, along with peer-reviewed literature — to support sound and objective decision-making and rationales in reviews.
Collaborate with other departments — Member Services, Provider Services, Pharmacy, Claims, and Contracting — to improve performance and address oncology-specific operational needs.
Opportunity to interact with Sales and Account Management in support of client needs, including oncology trend reporting, high-cost drug strategy, and client-facing clinical discussions.
Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.
Perform other duties as required by the business.