Medical Director, Vision

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.

Originally posted on Himalayas