Health Network One

• 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. • 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. • 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. • 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. • 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.

• Provide clinical oversight and medical direction for dermatology‑related programs and services. • Ensure clinical policies, guidelines, and practices align with evidence‑based dermatology standards of care and applicable regulatory requirements. • Serve as the senior clinical authority for dermatology‑related questions, escalations, and complex case reviews. • Perform and oversee utilization management reviews related to dermatology services. • Conduct medical necessity determinations for prior authorization, concurrent review, and retrospective review. • 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. • Act as a client‑facing clinical leader and dermatology specialist for Health Network One’s dermatology service lines. • Participate in client meetings, presentations, and consultations to explain dermatology clinical programs, utilization management decisions, and outcomes. • Support client relationships, retention, and growth by providing credible, data‑driven clinical guidance. • Represent Health Network One with external stakeholders, including health plans, provider partners, and regulatory entities, as appropriate. • Partner with the Chief Medical Officer and executive leadership team to support strategic planning, clinical program design, and growth initiatives for dermatology 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. • Ensure compliance with federal and state regulations, accreditation standards, and client contractual requirements. • Support quality management activities related to dermatology services, including audits, reporting, and corrective action planning. • Promote a culture of clinical excellence, accountability, and patient‑centered decision‑making.

• Build pricing and underwriting models and analyses to guide new deal pricing and review of existing pricing arrangements. • Perform detailed medical cost, utilization, and trend analyses to support rate development and pricing recommendations. • Evaluate profitability of quotes, renewals, and book-level performance relative to pricing assumptions. • Track performance of existing contracts. • Support evaluation of risk and pricing strategies for new and existing products through multiple scenarios, such as base, downside and upside cases. • Analyze and assess the integrity of the data being used for underwriting. • Identify and recommend mechanisms and contract terms that mitigate known and unknown risks and uncertainties. • Partner with operations, medical economics / business analytics, product, sales, account management and others as appropriate.

• Provide clinical oversight and medical direction for musculoskeletal and therapy related programs and services • Ensure clinical policies, guidelines, and practices align with evidence based PM&R and MSK standards of care and applicable regulatory requirements • Serve as the senior clinical authority for MSK related questions, escalations, and complex case reviews • Perform and oversee utilization management reviews for MSK services, including physical therapy, occupational therapy, and related interventions • 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 • Act as a client facing clinical leader and PM&R specialist for Health Network One’s MSK service lines • Participate in client meetings, presentations, and consultations to explain MSK clinical programs, utilization management decisions, and outcomes • Support client relationships, retention, and growth by providing credible, data driven clinical guidance • Represent Health Network One with external stakeholders, including health plans, provider partners, therapy networks, and regulatory entities, as appropriate • Partner with the CEO and executive leadership team to support strategic planning, clinical program design, and growth initiatives for MSK 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 • Ensure compliance with federal and state regulations, accreditation standards, and client contractual requirements • Support quality management activities related to MSK services, including audits, reporting, and corrective action planning • Promote a culture of clinical excellence, accountability, and evidence based decision making

• Preparing journal entries and conducting month end close task with minimal supervision. • Preparing account reconciliations, including bank accounts and credit card statements. • Reconciling intercompany balances. • Preparing documentation for external auditors. • Collaborating with preparation of annual budgets. • Preparing balance sheet reconciliations. • Ensures compliance with company HIPAA policies and procedures.

• Responsible for designing, developing, integrating, and supporting enterprise software solutions. • Application Design & Development: Develop and maintain enterprise applications using C#, ASP.NET, Web APIs, and microservices. • Build and optimize microservices architectures. • Develop and maintain SQL Server databases and integration components for EDI transactions. • Analyze complex legacy systems and develop modernization strategies. • Collaborate with business stakeholders to understand requirements and recommend process improvements. • Use Azure DevOps for work item management and participate in code reviews.

• Support the Controller in managing the financial operations of the organization. • Ensure compliance with healthcare regulations. • Maintain accurate financial records. • Prepare and review monthly, quarterly, and annual financial statements. • Manage and mentor a small team of accountants. • Prepare and analyze business unit profitability and cash flow projections. • Assist in budgeting, forecasting, and variance analysis. • Maintain and improve internal controls and financial systems. • Collaborate with the Controller and CFO on operating budgets and strategic initiatives. • Support audit and compliance processes.