Medical Director Utilization Management OncologyNew Cerritos, California, United States

About The Role

The Medical Director role provides clinical expertise in assessing the medical necessity, appropriateness, and efficiency of oncology care with a focus on direct utilization management for case review and clinical decision making. In this collaborative role, you will work with physicians, clinical teams and operational leaders to support evidence-based high quality and cost-effective care delivery across the network.

Key Responsibilities

• Conduct medical reviews and make independent clinical decisions of hematology and oncology treatment plans to determine medical necessity, appropriateness, and alignment with value-based clinical guidelines and evidence-based practices.
• Review and assess the appropriateness of ongoing cancer treatment plans, ensuring that they align with evidence-based medicine and clinical best practices.
• Provide clinical guidance and recommendations that balance quality, outcomes, and cost-effectiveness.
• Liaise with providers, insurance companies, and patients to clarify and discuss treatment options and coverage.
• Evaluate clinical and utilization data to identify trends, variations in care, and opportunities for improvement.
• Partner with clinical and operational teams to support value-based care.
• 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.

Qualifications

• Medical degree (MD or DO)
• Board Certification in Oncology
• Minimum of 5 years of clinical experience in oncology
• 2+ years of Utilization Management 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