Medical Director Utilization Management Oncology

The Oncology Institute of Hope and Innovation • Cerritos, CA

1d • Remote

About The Position

The Medical Director role provides clinical expertise in assessing the medical necessity, appropriateness, and efficiency of oncology care with a focus on direct utilization management for case review and clinical decision making. In this collaborative role, you will work with physicians, clinical teams and operational leaders to support evidence-based high quality and cost-effective care delivery across the network. You will also contribute to cross-functional initiatives, data-driven insights, and oversight of utilization management policies to optimize patient outcomes.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level