Medical Director Clinical PBM Operations

MedImpact Healthcare Systems, Inc.•San Diego, CA

47d•$188,204 - $357,587•Hybrid

About The Position

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution! The Medical Director provides enterprise-level clinical leadership across all pharmacy benefit management (PBM) operations at MedImpact. This role is responsible for ensuring clinical integrity, regulatory compliance, and operational excellence in formulary management, P&T governance, utilization management, drug information, appeals & grievances, quality, and accreditation. As a strategic physician leader, the Medical Director bridges clinical evidence, regulatory standards, and business strategy—ensuring that MedImpact delivers high-value, member-centered, and client-aligned pharmacy solutions that differentiates MedImpact.

Requirements

Doctor of Medicine (MD) or Osteopathy (DO) degree from an accredited medical education program.
Internship and Residency from an accredited program.
Board Certified in an accredited medical specialty by the American Board of Medical Specialties or equivalent accrediting body.
At least five years of direct patient care in a medical practice setting, either individual or group, along with minimum of 3-5 years of serving as a medical director in an HMO, medical group practice or PBM environment.
plus 12 years’ related experience; 10 years of SME in respective area(s); (or equivalent combination of education and experience); and 10 years supervisory experience; Supervisory experience may be substituted with 12 years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader at the Director level or above that must be completed within 12 months in new position.
Thorough knowledge of Microsoft Office, with emphasis on Word, Excel, Access, PowerPoint, Outlook, and Visio.
Current valid, unrestricted medical license, preferably in State of California, but in any state.
Must be licensed in states where statues require licensure to perform services.
Must maintain licensure, certification, and continuing medical education requirements in chosen field of medicine at all times.
Proven leadership in formulary governance, utilization management, drug information, or medical review.
Deep understanding of evidence-based medicine, pharmacoeconomics, and clinical policy development.
Strong knowledge of URAC/NCQA/CMS requirements, regulatory compliance, and appeals/grievance workflows.
Excellent communication, stakeholder management, and executive presentation skills.
Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
Ability to comprehend and apply principles of advanced calculus, modern algebra, and advanced statistical theory.
Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations.
Ability to write speeches and articles for publication that conform to prescribed style and format.
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.

Nice To Haves

Primary care board certification is preferred.
Prior leadership within a national PBM (CVS, Express Scripts, OptumRx) or large health plan.
Experience with specialty pharmacy, GLP-1 utilization strategies, and value-based contracting
Experience with Business Intelligence, Business Process Management, and Business Rules Management software.
To perform this job successfully, an individual must also gain a thorough understanding of MedImpact proprietary software tools related to formulary administration, pharmacy claims adjudication, and drug data management.

Responsibilities

Serve as the clinical leader and subject matter expert across the PBM enterprise, advising executive and operational leadership.
Lead the development of MedImpact’s clinical governance framework for formulary, P&T, and utilization management.
Partner with the Chief Medical Officer and Vice President, Clinical Operations, and cross-functional teams to align clinical strategy with client outcomes, cost of care, and quality metrics.
Lead and mentor a team of clinical professionals, promoting a culture of integrity, innovation, and accountability.
Represent MedImpact in client meetings, industry panels, and clinical advisory boards, strengthening the company’s thought leadership in value-based PBM solutions.
Chair or serve as executive medical liaison for the Pharmacy & Therapeutics (P&T) Committee, ensuring evidence-based formulary decisions.
Oversee drug monographs, class reviews, and pipeline drug assessments to inform coverage strategy.
Direct the creation and review of prior authorization, step therapy, and quantity limit criteria, balancing access, safety, and cost containment.
Provide clinical guidance on pipeline therapies, biosimilars, GLP-1s, specialty drugs, and gene therapies, aligning with enterprise strategy.
Oversee drug information and clinical policy functions, ensuring accuracy, timeliness, and defensibility of all clinical communications.
Provide executive oversight of clinical programs such as medication therapy management, adherence interventions, and real-world outcomes measurement.
Collaborate with Data & Analytics to evaluate the clinical ROI and health outcomes of formulary and utilization management programs.
Lead oversight for coverage determinations, exceptions, and appeals, ensuring adherence to CMS, state, and accreditation standards.
Implement peer review, inter-rater reliability, and quality audit protocols across all adjudication functions.
Support clinical staff with escalated or complex medical reviews and ensure consistency in decisions across the organization.
Drive URAC, NCQA, and CMS accreditation readiness for all clinical departments.
Lead clinical quality assurance programs, audit preparedness, and ongoing compliance monitoring.
Define and report on clinical KPIs, including overturn rates, audit outcomes, safety events, adherence improvements, and client satisfaction.
Partner with Operations, Product, and Innovation to ensure clinical programs are operationally executable and technologically enabled.
Collaborate with Client Success, Sales, and Marketing to provide clinical expertise in RFP responses, client renewals, and strategic presentations.
Engage externally with providers, consultants, and regulatory agencies to maintain MedImpact’s leadership in evidence-based pharmacy care.
Manage assigned staff in the segment area.
Responsible for the overall direction, coordination, and evaluation of the unit.
Carry out supervisory responsibilities in accordance with the organization's policies and applicable laws.
Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Supports and enforces all company policies and procedures in a fair and consistent manner, taking corrective action whenever necessary.