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.