Detroit, MI

This position is responsible for providing medical leadership to the organization by ensuring medical quality and adherence to professional and ethical medical standards by the plan and its network.

  • Provide medical leadership by balancing clinical decisions, health care trends and business necessities through new program development, peer review process, member grievances and appeals, corrective action,credentialing, quality programs for a Health Plan vs. hospital, clinical reviews for the UM Process, and making recommendations to Health leadership and management regarding provider competencies.
  • Participate in strategic planning efforts and ongoing management meetings by communicating business strategies from a clinical perspective. Provide proactive medical leadership consistent with Strategic Plan around business transformation.
  • Serve as a leader in the San Luis Obispo and Santa Barbara County medical communities by promoting high quality and cost effective health care amongst underserved and disenfranchised populations, and our members.
  • Responsible for developing, implementing and monitoring the Health Services Quality Improvement Plan, including quality of care, utilization management and peer review functions. Supervising the administration of the companies prospective, concurrent and retrospective review of health care program benefits. Assist in implementing and monitoring health management programs, developing clinical policies related to the use of the formulary and therapeutics, and overseeing the management of the pharmacy benefit program.
  • Consult in the development and implementation of quality of care policies and clinical guidelines for our members, monitor provider compliance, with an emphasis on utilization management and quality of care.
  • Oversee the administration concurrent and retrospective reviews of inpatient and long-term care services, issue denial of services when appropriate, review other medical claims and appeals as necessary.
  • Participate in the grievance process regarding quality of care issues with the ultimate resolution of medically related grievances.
  • Consult on the development of plans and policies related to health promotion for our members and continuing education for providers.
  • Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
  • Assist in departmental annual budgets.
  • Demonstrated and recognized employment history of visionary clinical and businessleadership in recent health care systems through experienced interaction with safety net providers and provider networks, community & clinical input, navigating human dynamics involving inter-departmental and community politics, use of data and analytics to identify clinical trends and outcomes that may require further understanding or investigation.
  • Understanding of regulatory and funding challenges with a deep understanding of medical economics.
  • Skilled at assertive and non-judgmental interaction with physician peers and other practitioners to motivate improvements in clinical practice to increase compliance with established clinical guidelines.


  • Doctor of Medicine, primary care specialty preferred. A minimum five years experience in a managed care plan and administering medical programs.
  • Knowledge of the California Medi-Cal program and Santa Barbara and San Luis Obispo medical communities preferred.
  • Excellent leadership skills required


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Contact us for more info:
Rebecka Boyd