Medical Director Utilization Management Oncology
About The Position
The Oncology Institute (TOI) is seeking a Utilization Management Medical Director Oncology to provide medical and strategic oversight of utilization management. This leadership role involves leading and developing a clinical Utilization Management team. The director will guide the evaluation of the clinical necessity and appropriateness of oncology treatments, ensuring cost-effective, evidence-based care without compromising patient outcomes. This position requires close partnership with executive, clinical, and operational leaders across the organization. TOI is dedicated to advancing oncology by delivering highly specialized, value-based cancer care in the community setting, offering cutting-edge, evidence-based cancer care including clinical trials and transfusions.
Requirements
- Medical degree (MD or DO)
- Board Certification in Oncology.
- Minimum of 5 years of clinical experience in oncology.
- 2+ years of Utilization Management 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.
Responsibilities
- Conduct medical reviews and make independent clinical decisions of hematology and oncology treatment plans to determine medical necessity, appropriateness, and alignment with value-based clinical guidelines and evidence-based practices.
- Review and assess the appropriateness of ongoing cancer treatment plans, ensuring that they align with evidence-based medicine and clinical best practices.
- Provide clinical guidance and recommendations that balance quality, outcomes, and cost-effectiveness.
- Liaise with providers, insurance companies, and patients to clarify and discuss treatment options and coverage.
- Evaluate clinical and utilization data to identify trends, variations in care, and opportunities for improvement.
- Partner with clinical and operational teams to support value-based care.
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
