Elevance Health
Overview
Medical Director - Medical Oncology role at Elevance Health (Carelon Medical Benefit Management). This is a Clinical Operations Medical Director position in Medical Oncology, Virtual: work virtually full-time with required in-person training sessions. Hybrid/virtual policy applies; candidates outside reasonable commuting distance may not be considered unless an accommodation is granted by law. Elevance Health, a member of the Elevance Health family, Carelon Medical Benefits Management (formerly AIM Specialty Health), is a benefit-management leader delivering cost-of-care savings across oncology and other clinical domains. The Clinical Operations Medical Director is responsible for supporting the medical management staff to ensure timely and consistent medical decisions for members and providers.
Responsibilities
Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care. Perform physician-level case review, following initial nurse review, of chemotherapy regimens. Determine medical necessity of requests using guidelines and client-specific health plan medical policy. 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. Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application. Demonstrate and maintain current knowledge of new cancer treatment regimens. Assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing as needed. Participate in periodic physician team meetings. Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care. Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert. Perform first level provider appeals as designated by the client for adverse determinations. Obtain additional state licensure based upon business needs. Adhere to all company protocols, policies, and procedures. Ensure timely completion of clinical case reviews for the board-certified specialty. Make physician-to-physician calls to gather medical information to make medical necessity determinations for services requested. Make medical necessity determinations for grievance and appeals appropriate for the specialty. Ensure consistent use of company medical policies when making medical necessity decisions. Bring to supervisors’ attention any case review decisions requiring Medical Director review or policy interpretation.
Minimum Requirements
MD or DO with Board certification approved by ABMS or AOA, where applicable to duties performed. Active unrestricted medical license to practice medicine or a health profession. Minimum of 1 year of experience with clinical case reviews for medical necessity; this requirement may be waived for Cardiology, Oncology, and Interventional Pain specialties. Board certification in a medical specialty is required.
Preferred Qualifications
Board Certification in Medical Oncology strongly preferred. 3–5 years of clinical practice experience past fellowship training is desirable. Demonstrated knowledge of current practice standards in oncology.
Compensation and Location
For candidates working in person or virtually in the listed location(s), the salary range is $215,255 to $322,883. Location: Illinois. Elevance Health offers benefits including a comprehensive package, incentive programs, equity stock purchase, and 401(k) contributions. Salary is based on legitimate, non-discriminatory factors and is not considered wages until earned and determinable under applicable policies and plans. Bonus, benefits, and other compensation are at the Company’s discretion, in compliance with laws.
Notes
Please note Elevance Health accepts resumes for compensation from agencies only with a signed agreement. Unsolicited resumes submitted to hiring managers are the property of Elevance Health.
Who We Are. Elevance Health is a health company dedicated to improving lives and communities. We are a Fortune 25 company seeking leaders passionate about impacting members and the communities we serve.
How We Work
We offer market-competitive total rewards including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical/dental/vision, disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs, and financial education resources. Elevance Health operates a Hybrid Workforce Strategy; time onsite requirements will be discussed during the hiring process. Vaccination policies may apply for certain patient-facing roles, in line with laws. Elevance Health is an Equal Employment Opportunity employer. Accommodations in the application process are available upon request. Qualified applicants with arrest or conviction records will be considered consistent with applicable laws.
Locations: Illinois
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Medical Director - Medical Oncology role at Elevance Health (Carelon Medical Benefit Management). This is a Clinical Operations Medical Director position in Medical Oncology, Virtual: work virtually full-time with required in-person training sessions. Hybrid/virtual policy applies; candidates outside reasonable commuting distance may not be considered unless an accommodation is granted by law. Elevance Health, a member of the Elevance Health family, Carelon Medical Benefits Management (formerly AIM Specialty Health), is a benefit-management leader delivering cost-of-care savings across oncology and other clinical domains. The Clinical Operations Medical Director is responsible for supporting the medical management staff to ensure timely and consistent medical decisions for members and providers.
Responsibilities
Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care. Perform physician-level case review, following initial nurse review, of chemotherapy regimens. Determine medical necessity of requests using guidelines and client-specific health plan medical policy. 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. Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application. Demonstrate and maintain current knowledge of new cancer treatment regimens. Assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing as needed. Participate in periodic physician team meetings. Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care. Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert. Perform first level provider appeals as designated by the client for adverse determinations. Obtain additional state licensure based upon business needs. Adhere to all company protocols, policies, and procedures. Ensure timely completion of clinical case reviews for the board-certified specialty. Make physician-to-physician calls to gather medical information to make medical necessity determinations for services requested. Make medical necessity determinations for grievance and appeals appropriate for the specialty. Ensure consistent use of company medical policies when making medical necessity decisions. Bring to supervisors’ attention any case review decisions requiring Medical Director review or policy interpretation.
Minimum Requirements
MD or DO with Board certification approved by ABMS or AOA, where applicable to duties performed. Active unrestricted medical license to practice medicine or a health profession. Minimum of 1 year of experience with clinical case reviews for medical necessity; this requirement may be waived for Cardiology, Oncology, and Interventional Pain specialties. Board certification in a medical specialty is required.
Preferred Qualifications
Board Certification in Medical Oncology strongly preferred. 3–5 years of clinical practice experience past fellowship training is desirable. Demonstrated knowledge of current practice standards in oncology.
Compensation and Location
For candidates working in person or virtually in the listed location(s), the salary range is $215,255 to $322,883. Location: Illinois. Elevance Health offers benefits including a comprehensive package, incentive programs, equity stock purchase, and 401(k) contributions. Salary is based on legitimate, non-discriminatory factors and is not considered wages until earned and determinable under applicable policies and plans. Bonus, benefits, and other compensation are at the Company’s discretion, in compliance with laws.
Notes
Please note Elevance Health accepts resumes for compensation from agencies only with a signed agreement. Unsolicited resumes submitted to hiring managers are the property of Elevance Health.
Who We Are. Elevance Health is a health company dedicated to improving lives and communities. We are a Fortune 25 company seeking leaders passionate about impacting members and the communities we serve.
How We Work
We offer market-competitive total rewards including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical/dental/vision, disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs, and financial education resources. Elevance Health operates a Hybrid Workforce Strategy; time onsite requirements will be discussed during the hiring process. Vaccination policies may apply for certain patient-facing roles, in line with laws. Elevance Health is an Equal Employment Opportunity employer. Accommodations in the application process are available upon request. Qualified applicants with arrest or conviction records will be considered consistent with applicable laws.
Locations: Illinois
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