Clinical Pharmacist IV - Regulatory
About The Position
Medica is a nonprofit health plan serving over a million members across multiple states. They focus on delivering personalized healthcare and collaborating with providers. The Clinical Pharmacist – Regulatory role supports the Pharmacy department's oversight of state and federal clinical requirements and compliance through reporting, requirements review, interpretation, and audit activities. This position also oversees delegated clinical activities for pharmacy and medical pharmacy reviews, performs internal clinical reviews (initial and appeals) for Medicare, Medicaid, and Commercial/IFB cases, and collaborates with other departments, regulators, and external parties to ensure regulatory compliance for pharmacy services. Performs other duties as assigned.
Requirements
- Bachelor of Science in Pharmacy or PharmD required
- 5+ years of experience in health plan pharmacy, PBM clinical management, or related clinical leadership role beyond degree
- Active Pharmacist license required
Nice To Haves
- Familiarity with the clinical review process for prior authorization requests
- Health plan delegate oversight
- Audit and compliance activities
- Experience working within regulated environments (Medicare and/or Medicaid)
- Board certification (e.g., BCPS or other relevant specialty)
- Experience in plan led or hybrid PBM models
- Familiarity with accreditation and regulatory frameworks (e.g., CMS, NCQA)
- Clinical credibility and sound judgment
- Strong governance mindset and attention to consistency
- Ability to translate evidence into practical, defensible clinical positions
- Executive level presentation and communication skills
- Collaborative, cross functional leadership
Responsibilities
- Review and interpret new regulatory guidance (e.g., HPMS memos, statutes) and its applicability to Medica pharmacy processes. Ensure Medica is prepared to meet new regulatory requirements by communicated deadlines.
- Support Medica’s Pharmacy department in responding to regulatory audits and compliance inquiries. Support end-to-end resolution of audit and compliance items from engagement to corrective action plan completion. Coordinate and assist in responses to pharmacy regulatory audits with internal Government Relations and Compliance departments.
- Support required regulatory submissions for all regulators.
- Provide clinical pharmacy support for NCQA initiatives, projects, and audits.
- Develop and maintain Policies and Procedures related to pharmacy regulatory processes.
- Oversee clinical review activities delegated to PBM and Medical Drug Vendor.
- Provide oversight of clinical services and programs delegated to PBM and medical drug vendor.
- Assist with audits and other regulatory activities with pharmacy delegate impacts.
- Oversee monitoring activities and reporting to ensure appropriate compliance with regulatory requirements and specific clinical initiatives.
- Evaluate the pharmacy and medical pharmacy benefits to ensure regulatory compliance.
- Identify opportunities for clinical monitoring programs and support the maintenance of existing monitoring initiatives.
- Perform internal clinical reviews, both initial and appeals, for select Medicare, Medicaid and Commercial/IFB cases.
- Assist with identifying and recommending efficiencies for clinical review processes including coverage criteria and denial language.
- Compliance with applicable federal and state rules and regulations, guidance, and statutes for all lines of business while completing clinical reviews.
- Provide support to operational teams on various requests including resolving clinical pharmacy-related inquiries from members, providers, and/or pharmacies.
Benefits
- competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
