Clinical Operations Medical Director
Medical Oncology
Carelon Medical Benefit Management
Virtual : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
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 is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.
How you will make an impact:
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.
As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered treatments and genetic testing.
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.
Ensures timely completion of clinical case reviews for their board certified specialty.
Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested.
Makes medical necessity determinations for grievance and appeals appropriate for their specialty.
Ensures consistent use of company medical policies when making medical necessity decisions.
Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation.
Minimum Requirements:
Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Must possess an active unrestricted medical license to practice medicine or a health profession.
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.
Board certification in a medical specialty 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
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $215,255 to $322,883
Locations: Illinois
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 .
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.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
