Appeals Medical Director - Oncology

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. Candidates must be within a reasonable commuting distance from the posting location(s) unless an accommodation is granted as required by law.

About the role

The Appeals Medical Director for Oncology is responsible for appeal reviews for physical health medical services to ensure appropriate and cost-effective medical care. May develop and implement programs to improve quality, cost, and outcomes, provide clinical consultation, and serve as a clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities.

Responsibilities

• Support clinicians to ensure timely and consistent responses to members and providers.
• Provide guidance for clinical operational aspects of a program.
• Conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers to discuss review determinations.
• Serve as a resource and consultant for other areas of the company.
• Represent the company to external entities and/or serve on internal and/or external committees.
• Chair company committees.
• Interpret medical policies and clinical guidelines.
• Develop and propose new medical policies based on changes in healthcare.
• Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
• Identify and develop opportunities for innovation to increase effectiveness and quality.

Requirements

• Requires MD or DO and Board certification approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable.
• Must possess an active unrestricted medical license to practice medicine or a health profession.
• Must be located in a state or territory of the United States when conducting utilization review or appeals consideration (unless expressly allowed by law).
• Minimum of 10 years of clinical experience; or any combination of education and experience which would provide an equivalent background.
• For Health Solutions and Carelon organizations, minimum of 5 years of experience providing healthcare is required.
• Additional experience may be required by State contracts or regulations if filing a role required by a State agency.

Qualifications

• Board certification in Oncology or Hematology and Oncology strongly preferred.
• Utilization Management or Appeals experience preferred.

Pay

For candidates working in person or virtually in California, Columbus OH, District of Columbia, Illinois, Maryland, Massachusetts, New Jersey, New York, and Virginia, the salary range for this position is $247,840 to $446,112. The salary offered is based on geographic location, work experience, education, and skill level, among other factors.

Benefits

• Comprehensive benefits package, including medical, dental, vision, short and long-term disability, and 401(k) with company match.
• Incentive and recognition programs.
• Equity stock purchase plan.
• Paid holidays and Paid Time Off (PTO).
• Life insurance, wellness programs, and financial education resources.

Schedule

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, with specific requirements discussed during the hiring process.