Senior Medical Director Utilization Management Oncology

About The Oncology Institute (www.theoncologyinstitute.com): 
Founded in 2007, The Oncology Institute (NASDAQ: TOI) is advancing oncology by delivering highly specialized, value-based cancer care in the community setting. TOI offers cutting-edge, evidence-based cancer care to a population of approximately 1.9 million patients, including clinical trials, transfusions, and other care delivery models traditionally associated with the most advanced care delivery organizations. With over 180 employed and affiliate clinicians and over 100 clinics and affiliate locations of care across five states and growing, TOI is changing oncology for the better. 

Senior Medical Director Utilization Management Oncology

Work Location: REMOTE (work from home)

California         Nevada               Arizona               Oregon                Florida

As a Senior Medical Director, Utilization Management, you will report directly to the Chief Clinical Officer and support key C-suite clinical initiatives. This is a leadership role with responsibility for providing medical and strategic oversight of utilization management while leading and developing a clinical Utilization Management team. You will guide the evaluation of the clinical necessity and appropriateness of oncology treatments, ensuring cost-effective, evidence-based care without compromising patient outcomes, while partnering closely with executive, clinical, and operational leaders across the organization.

 Key Responsibilities:

• Provide strategic and clinical leadership to the Utilization Management team, fostering high performance, accountability, and consistent application of evidence-based oncology standards.


• Build trusted relationships with the Utilization Management team and TOI and affiliated physicians to drive alignment on clinical guidelines, utilization decisions, and patient focused care.


• Coach and educate the Utilization Management team and physicians on oncology utilization standards, fostering shared accountability for quality, cost effective patient care.


• Development of strategy development to support scalable growth across TOI network.


• Conduct medical reviews of hematology and oncology treatment plans to determine medical necessity, appropriateness, and alignment with value-based clinical guidelines and evidence-based practices.


• Evaluate clinical data and collaborate with healthcare providers to ensure optimal utilization of resources for oncology patients.


• Make independent clinical decisions on the appropriateness of treatments, imaging, and interventions based on established medical standards.


• Provide expert guidance and recommendations on appropriate oncology treatments while considering cost-effectiveness and patient care quality.


• Liaise with providers, insurance companies, and patients to clarify and discuss treatment options and coverage.


• 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.


• Review and assess the appropriateness of ongoing cancer treatment plans, ensuring that they align with evidence-based medicine and clinical best practices.

Qualifications:

• Medical degree (MD or DO)


• Board Certification in Oncology.


• Minimum of 5 years of clinical experience in oncology.


• 3+ years of Utilization Management leadership 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.