Director Clinical Operations and Medical Policy

Cambia Health Solutions • Fargo, ND

17h • Hybrid

About The Position

Every day, Cambia’s dedicated team of Pharmacy leaders are living our mission to make health care easier and lives better. As a member of the Pharmacy Services leadership team, our Director Clinical Operations and Medical Policy develops strategy, directs, and oversees clinical pharmacy activities and services. These activities include services pertaining to: evidence reviews of medications, formulary development, Pharmacy and Therapeutics (P&T) Committee support, medication use policy development, the Medication Policy Group (MPG), clinical prior authorization, implementation of utilization management activities, guidance for clinical edit coding for prescription claims processor or medical claims system, medication pipeline monitoring, medication trend management, and consultation and guidance on medication-related issues. The scope includes medications covered under the pharmacy benefit, medical benefit and specialty medications – all in service of creating a person-focused health care experience. As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us. Do you want to lead a team that bridges clinical pharmacy expertise with health policy development, overseeing everything from P&T Committee support to utilization management in a mission-driven organization? Are you looking for an opportunity to drive clinical pharmacy innovation where your strategic leadership in medication policy, prior authorization, and formulary management creates meaningful impact for members across multiple benefit types? Then this role may be the perfect fit.

Requirements

• Bachelor's degree in Pharmacy or PharmD
• Minimum of five years of management or professional business experience in a managed health care system, medical group, hospital, or related business in health care delivery industry or an equivalent combination of education and experience
• Licensed pharmacist in state of practice
• Demonstrated strong clinical pharmacy background with ability to demonstrate clinical therapy skills and knowledge
• Demonstrated strong knowledge of health care economics and financing; health care industry dynamics; and provider contracting strategies, techniques, and processes
• Demonstrated success in managing professional business relationships in a managed care system, medical group, hospital, or related business in health care delivery industry
• Excellent verbal and written communication skills; strong business analytical skills and abilities; strong project management and coordination ability; ability to function effectively as a management team member
• Demonstrated knowledge of the following: Health Plan and benefit design structures and application; Medicare/CMS regulations and applicability in administering the Medicare Product; Pharmaceutical products, including orals, injectables, infusion products, and chemotherapy; Knowledge of health care coding and payment systems (such as ICD-10, CPT, HCPCS, NDC); Compliance related activities, legislative and regulatory activities, health insurance operations, or legal research helpful; state and federal laws and rules regarding the practice of pharmacy and regulation of health care industry practices, such as DOLI, PPACA and HIPAA
• Demonstrated ability to leverage AI tools and resources to drive efficiency and innovation within area of expertise

Nice To Haves

• Residency certificate or advanced degree in health care administration, economics, public health, pharmacy administration, finance, or equivalent field preferred

Responsibilities

• Lead and direct clinical pharmacy services that align with organizational strategic goals, managing nearly $2B of annual drug expense across all lines of business while ensuring compliance with state, federal, and CMS regulations
• Provide vision, direction, and leadership to Clinical Pharmacy Services team of managers and staff, overseeing work activities, developing budgets, and implementing change management plans to achieve strategic objectives
• Direct pharmacy formulary, medication policy, prior authorization, and utilization management activities for commercial, Medicare, and Health Insurance Marketplace lines of business, including product review, market analysis, coverage guidelines development, and clinical support of the pharmacy appeal process
• Be accountable for the Pharmacy and Therapeutics (P&T) Committee, Medication Policy Group (MPG), Pharmacy Business Committee and related governance committees, while managing development, maintenance, and submission of Medicare and QHP formularies
• Direct and oversee medication use programs to encourage best value medications and discourage unsafe or low clinical value medications, including medication pipeline management and strategies to manage pharmacy trend drivers
• Collaborate internally across departmental teams (customer services, provider relations, sales/marketing, operations, medical services, contracting/rebates, analytics) and externally with healthcare professionals and key vendors including the Pharmacy Benefit Manager (PBM) to optimize programs supporting medication access, quality, and affordability
• Ensure ongoing evaluation and quality improvement of evidence-based medication technology assessment methods, develop performance metrics with routine reporting and analysis, coordinate resources to address clinical pharmacy issues, and contribute to corporate quality initiatives through process improvement teams

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Director