Medical Director

• 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 appropriate utilization of covered treatments and genetic testing
• Participate in periodic physician team meetings and on committees or work groups as needed
• Maintain knowledge of relevant policies and regulations pertaining to utilization review of oncology care
• Perform first level provider appeals for adverse determinations as designated by the client
• Obtain additional state licensure as needed
• Ensure timely completion of clinical case reviews and consistent use of company medical policies
• Make physician-to-physician calls to gather medically appropriate information and make medical necessity determinations for grievance and appeals

Medical Director – Medical Oncology

Senior Clinical Development Medical Director – NS

Associate Medical Director

Cardiology Medical Director

Medical Director, Diagnostic Cardiology

Medical Director – Plan Performance