Description
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.