Director, Clinical Services

Prescryptive Health, Inc.

About The Position

Prescryptive Health is a healthcare technology company delivering solutions that empower consumers. Prescryptive’s secure, mobile-first products connect consumers, pharmacists, and employers, ultimately providing people with the information they need to make informed decisions and take control of their health. To learn more about Prescryptive Health, visit Prescryptive.com. About this role We're seeking a hands-on, experienced and execution-oriented Director, Clinical Services to design, own, and optimize our clinical programs and formulary operations. This role goes beyond traditional formulary maintenance—you'll be the clinical authority driving program development, policy creation, and system automation that directly impacts cost, quality, and member outcomes. The ideal candidate brings deep PBM experience, a proven track record of success and thrives in building systematic quality assurance into clinical operations from the ground up.

Requirements

PharmD from an ACPE-accredited college of pharmacy
Active pharmacist license
Minimum 5 years of PBM experience with demonstrated expertise in formulary management and utilization management
Proven track record of designing and implementing clinical programs with measurable outcomes
Strong understanding of pharmacy benefit design, drug utilization management, and clinical guidelines
Experience with specialty pharmaceuticals, biosimilars, and limited distribution drugs
Knowledge of rebate compliance, contracting, and lowest net cost strategies
Proficiency with pharmacy claims adjudication platforms and NCPDP standards
Experience translating vendor clinical criteria into operational logic
Advanced analytical skills with ability to interpret claims data and identify trends
Excellent project management capabilities with ability to manage multiple priorities

Nice To Haves

Board certification (BCPS, BCACP, or relevant specialty)
Experience with Formulary Navigator or similar formulary management systems
Hands-on experience with First DataBank (FDB) and/or Medispan drug files
Background in clinical program development for GLP-1/weight loss management and/or opioid management
Experience in startup or high-growth healthcare technology environments
Familiarity with transparent pricing models and value-based pharmacy benefits
Experience with fraud, waste, and abuse (FWA) detection programs
Understanding of pharmacy network operations, BIN/PCN routing, and Surescripts protocols
Advanced proficiency with MS Office, particularly Excel and Access
Experience coordinating P&T committees

Responsibilities

Clinical Program Ownership & Development Design, build and own comprehensive clinical programs (e.g., GLP-1 weight loss management, opioid management, fraud/waste/abuse detection) including program objectives, clinical guardrails, and success metrics
Define clinical policy and intent behind prior authorization criteria and utilization management controls
Serve as the internal clinical authority and point of contact for complex clinical questions and policy decisions
Translate clinical guidelines and evidence into actionable interventions that balance member access with cost management
Formulary Strategy & Management Design, implement, and maintain drug formularies that balance clinical efficacy, safety, and cost-effectiveness with lowest net cost strategies
Conduct therapeutic class reviews and drug evaluations using evidence-based clinical criteria, considering rebate compliance, market trends, and clinical literature
Manage formulary updates in response to new drug approvals, pipeline changes, and evolving clinical evidence
Ensure accurate implementation of Limited Distribution Drug (LDD) classifications and specialty medication criteria
Monitor and ensure formulary compliance with regulatory requirements across the Prescryptive book of business
Prior Authorization & Utilization Management Develop and manage PA criteria that are clinically sound, medication-specific, and operationally effective
Interpret and restructure and directly configure vendor criteria (e.g., MCG, InterQual) into Prescryptive-specific logic for initial builds and major program changes
Provide clinical direction for PA content in Formulary Navigator and downstream adjudication systems
Create utilization management tools including step therapy protocols, quantity limits, and clinical edits that support program goals
System Integration & Automation Lead Formulary Navigator buildout and drive automation of drug list processes
Ensure formulary data accuracy across multiple platforms through systematic testing and quality assurance initiatives
Collaborate directly with technical teams to translate clinical requirements into system configurations
Validate implementation of formulary changes in adjudication systems
Analytics & Data-Driven Decision Making Partner with Analytics team on targeting logic, intervention design, and performance dashboards
Analyze claims data to identify trends, cost savings opportunities, and program effectiveness
Translate data insights into clinical interventions and program refinements
Establish and monitor metrics for clinical program success
Apply emerging AI-enabled tools in a hands-on way to support clinical program build, optimization, and quality assurance as programs scale
Client & Stakeholder Collaboration Support client-facing clinical discussions and explain coverage rationale with clinical credibility
Approve and guide client-specific clinical customizations and formulary solutions
Develop project plans to ensure appropriate implementation of client program requirements
Coordinate Pharmacy & Therapeutics (P&T) committee activities and drug evaluation processes
Communicate formulary changes and program updates to internal and external partners
Create and update clinical marketing materials
Quality Assurance & Compliance Build quality assurance into formulary design from inception, emphasizing prevention over inspection
Ensure compliance with federal and state regulations, including ERISA requirements where applicable
Maintain documentation supporting formulary decisions for audit and regulatory purposes
Monitor pharmacy benefit legislation and policy changes that impact formulary management