Key Responsibilities:
Clinical Leadership and Oversight
- Provide clinical oversight and medical direction for vision related programs and services.
- Ensure clinical policies, guidelines, and practices align with evidence based ophthalmology standards and applicable regulatory requirements.
- Serve as the senior clinical authority for ophthalmology related questions, escalations, and complex case reviews.
- Ensure compliance with GAAP, healthcare-specific regulations, and internal policies.
Utilization Management, Appeals, and Denials
- Perform and oversee utilization management reviews related to ophthalmology and vision services.
- Conduct medical necessity determinations for prior authorization, concurrent, and retrospective reviews.
- Review and adjudicate clinical appeals and denials, including peer to peer discussions with ordering and rendering providers.
- Collaborate with operational and compliance teams to ensure utilization management activities meet contractual, regulatory, and accreditation standards.
Client-Facing Clinical Leadership
- Act as a client‑facing clinical leader and ophthalmology specialist for Health Network One’s vision service lines.
- Participate in client meetings, presentations, and consultations to explain clinical programs, utilization management decisions, and outcomes.
- Support client relationships, retention, and growth by providing credible, thoughtful clinical guidance.
- Represent Health Network One with external stakeholders, including health plans, provider partners, and regulatory entities, as appropriate.
Strategic and Executive Partnership
- Partner with the CEO and executive leadership team to support strategic planning, clinical program design, and growth initiatives for vision services.
- Provide clinical insight to inform organizational decision making, risk management, and performance improvement efforts.
- Contribute to the development and refinement of clinical workflows, quality initiatives, and performance metrics aligned with organizational goals.
Compliance and Quality
- Ensure compliance with federal and state regulations, accreditation standards, and client contractual requirements.
- Support quality management activities related to ophthalmology and vision services, including audits, reporting, and corrective action planning.
- Promote a culture of clinical excellence, accountability, and patient centered decision making.
Qualifications:
Required
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) with specialty training in Ophthalmology.
- Active, unrestricted medical license in at least one U.S. state, with the ability to obtain additional licensure as needed.
- Board certified or board eligible in Ophthalmology.
- Demonstrated experience with utilization management, medical necessity review, appeals, and denials.
- Strong executive level communication skills, including the ability to engage effectively with clients, providers, and senior leaders.
Preferred
- Experience in managed care, health plans, MSOs, or delegated specialty or vision services.
- Prior experience in a physician executive or client facing clinical leadership role.
- Familiarity with regulatory and accreditation standards related to utilization management and quality programs
Key Competencies:
- Physician executive judgment and credibility.
- Client facing communication and presentation skills.
- Strong clinical decision making and documentation.
- Ability to balance clinical integrity with operational and business priorities.
- Collaborative, strategic leadership approach.
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