About the Role 

Brighton Health Plan Solutions (BHPS), a full-service health plan administrator, is seeking a part-time, board-certified oncologist to serve as Medical Director, Oncology. You will be the clinical lead for oncology utilization review across our Commercial and Workers’ Compensation self-funded clients, supporting our team of nurses, social workers, and coordinators in making medical necessity and benefit coverage determinations for cancer care. 

In this role, you will focus specifically on reviews of medical and surgical oncology, hematology-oncology, chemotherapy and immunotherapy regimens, high-cost specialty and infusion drugs (including biosimilars), supportive oncology therapies, and radiation oncology services. You will apply evidence-based criteria to determine the appropriateness of proposed therapies, advise on site-of-care redirection, and serve as a clinical resource for the medical management team and our clients. 

The position can be remote or on-site in our New York office. You have a passion to make cancer care more effective and affordable, and you bring the clinical judgment and collaborative style required to guide complex oncology decisions while supporting our nurses, providers, and members. 

Primary Responsibilities 

Oncology Utilization Review 

• Review oncology cases and make coverage and medical necessity determinations for chemotherapy, immunotherapy, targeted therapy, hormonal therapy, and supportive care regimens using NCCN Guidelines, MCG, CMS NCDs/LCDs, specialty society guidelines, peer-reviewed literature, and proprietary medical policies. 

• Review high-cost specialty and infusion drug requests — including biologics, biosimilars, CAR-T cell therapies, bispecific antibodies, antibody-drug conjugates, and other oncology agents — applying appropriate step therapy, biosimilar preference, and site-of-care criteria. 

• Review radiation oncology requests, including IMRT, SBRT, SRS, proton beam therapy, brachytherapy, and radiopharmaceuticals, for medical necessity and appropriate clinical indication. 

• Review requests for diagnostic imaging, genomic and molecular testing, surgical oncology services, bone marrow and stem cell transplantation, and other oncology-adjacent services. 

• Support the Slate Drug Infusion PA Redirect Program and similar high-cost drug and site-of-care redirection initiatives, working closely with the medical management, pharmacy, and clinical operations teams. 

• Provide clinical support for all areas of Medical Affairs relating to oncology. 

Clinical Team Support & Case Management 

• Advise team nurses on appropriateness of oncology care across the continuum — including infusion centers, hospitals, skilled nursing facilities, hospice, and home care — to ensure quality, cost-efficiency, and continuity of care. 

• Serve as the oncology medical expert for care management; review and evaluate cases with review nurses and ensure oncology care provided meets the standards for acceptable medical care. 

• Support nurses, social workers, and coordinators in improving their knowledge, independence, and understanding of oncology utilization and benefit determinations. 

• Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance oncology program performance. 

Peer-to-Peer & Provider Engagement 

• Make appropriate outreach to community and academic-based treating oncologists, hematologists, and radiation oncologists wishing to discuss cases. 

• Conduct peer-to-peer discussions with attending physicians to review clinical information, including cases where a proposed therapy or service cannot be certified. 

• Communicate certification decisions to the UR nurse within appropriate time frames as guided by URAC, ERISA, or state regulations. 

Appeals, Grievances & Quality of Care 

• Review and resolve grievances related to oncology medical quality of care and actively participate in the functioning of the plan’s grievance and appeals processes. 

• Identify, critique, and utilize criteria and resources — including NCCN, ASCO, ASTRO, ASH, and other national, state, and professional association guidelines, along with peer-reviewed literature — to support sound and objective decision-making and rationales in reviews. 

Cross-Functional Collaboration & Client Support 

• Collaborate with other departments — Member Services, Provider Services, Pharmacy, Claims, and Contracting — to improve performance and address oncology-specific operational needs. 

• Opportunity to interact with Sales and Account Management in support of client needs, including oncology trend reporting, high-cost drug strategy, and client-facing clinical discussions. 

• Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job. 

• Perform other duties as required by the business. 

Essential Qualifications 

• Board-certified MD or DO in Medical Oncology, Hematology-Oncology, or Radiation Oncology by the American Board of Medical Specialties or the American Board of Osteopathic Specialties. 

• 3+ years of prior clinical oncology practice, with active familiarity treating solid tumors and/or hematologic malignancies, and a demonstrated commitment to staying current on rapidly evolving oncology therapeutics. 

• 3+ years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations, including oncology reviews. 

• Current, unrestricted clinical license(s); New York licensure preferred or willingness to obtain. 

• Excellent understanding of the utilization and case management process as applied to oncology care. 

• Working knowledge of NCCN Guidelines, ASCO/ASTRO/ASH guidelines, MCG oncology content, CMS NCDs/LCDs, and evidence-based standards for medical and radiation oncology. 

• Familiarity with oncology medical billing and coding, including HCPCS J-codes and Q-codes for chemotherapy and biologic agents, CPT codes for infusion and radiation oncology services, and ICD-10 oncology coding. 

• Self-motivated to stay up to date on a broad range of oncology and supportive-care services using MCG guidelines, specialty society guidelines, UpToDate, NCCN, and other resources to analyze complex cases. 

• Ability to communicate clearly and concisely, both verbally and in writing, including in peer-to-peer discussions with treating oncologists. 

• Good interpersonal and communication skills to support the team approach. 

• Demonstrated computer and telephonic skills. 

Preferred Qualifications 

• Specialty training or fellowship beyond a first board certification in a subspecialty such as Hematology, Bone Marrow Transplant/Cellular Therapy, or a disease-specific oncology area. 

• Prior experience as a Medical Director or physician reviewer at a health plan, PBM, TPA, or managed care organization focused on oncology and/or specialty drug review. 

• Experience with oncology pathway programs, site-of-care redirection, and biosimilar preference strategies. 

• Familiarity with ZeOmega Jiva or a comparable medical management platform. 

• Experience with Workers’ Compensation oncology cases a plus. 

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

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