This role focuses on radiation oncology utilization management, including prior authorization, concurrent review, predetermination, peer-to-peer calls, and first-level appeals for oncology-related services. The clinician also supports medical policy implementation, clinical and reimbursement review, and case management when needed. It is a remote, full-time medical director position with some quarterly travel and on-call rotation.
Key Responsibilities
- Conduct prior authorization, pre-certification, concurrent review, and predetermination reviews for oncology services.
- Provide peer-to-peer consultation, first-level appeal review, and claim determination support.
- Support medical policy implementation and quality assurance across oncology utilization programs.
- Provide clinical, coding, and reimbursement expertise to support medical management decisions.
- Direct case management activities when needed and help ensure timely responses to members and providers.
- Participate in clinical team activities, committee work, special projects, and weekend/holiday/on-call rotation.
- Collaborate with network providers, facilities, and internal medical management staff to support oncology programs.
- Contribute to the development, implementation, and evaluation of clinical and medical management initiatives.
Required
- MD or DO degree.
- Current, active U.S. state medical license in good standing.
- Board certification in Radiation Oncology through ABMS or AOA.
- Eligibility to obtain additional state licensure as needed.
- At least 3 years of relevant radiation oncology experience in patient care or managed care after residency.
Preferred
- Previous utilization management experience with a health plan or payer.
- Previous utilization management experience as a physician advisor in a health system or hospital system.
Benefits & Perks
- Remote work from home anywhere in the United States.
- Full-time, exempt-level role.
- Eligibility for bonus, commission, or short-term incentive program.
- Equity award program eligibility.
- Comprehensive benefits package including medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other colleague resources.