Elevance Health

Utilization Management of Medical Oncology Benefits. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.. Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application.. As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing.. Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care.

utilization review

Clinical Operations Medical Director
Utilization Management of Medical Oncology Benefits
Carelon Benefits Management
$20,000 Sign On Bonus
Location : The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations with the opportunity to work remotely from home.
A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.
The Clinical Operations Medical Director supporting our Medical Oncology team is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.
Job Summary:
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Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care.
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Perform physician-level case review, following initial nurse review, of chemotherapy regimens.
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Determine medical necessity of requests using guidelines and client-specific health plan medical policy.
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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.
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Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application.
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Demonstrate and maintain current knowledge of new cancer treatment regimens.
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As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing.
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Participate in periodic physician team meetings.
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Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care.
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Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert.
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Perform first level provider appeals as designated by the client for adverse determinations.
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Obtain additional state licensure based upon business needs.
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Adhere to all company protocols, policies, and procedures.
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Minimum Requirements:
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Requires an MD and minimum of 1 year of experience with clinical case reviews for medical necessity. The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only; Cardiology, Oncology, and Interventional Pain specialties.
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Board certification in a medical specialty required.
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??????? Preferred Qualifications:
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Board Certification in Medical Oncology strongly preferred.
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3-5 years of clinical practice experience past fellowship training is desirable.
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Demonstrated knowledge of current practice standards in oncology.
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Strong oral communication and interpersonal skills.
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Intermediate computer skills (including MS Office and Outlook), ability to learn new applications.
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Strong analytical skills.
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Ability to multi-task.
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Ability to work both independently and in a team environment.
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Ability to work in a dynamic, fast-paced environment.
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For candidates working in person or remotely in the below locations, the salary* range for this specific position is $188,177 to $338,707.
Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .
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<li>The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. </li>
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