Pharmacy Clinical Governance Manager

Medica•St. Louis, MO

13d•$113,400 - $194,400•Hybrid

About The Position

The Pharmacy Clinical Governance Manager is responsible for leading the development, maintenance, and oversight of the health plan’s enterprise clinical pharmacy positions across all drug classes and lines of business (Individual, Commercial, Medicare, and Medicaid). This role ensures consistent, evidence based clinical decision making through strong governance processes, high quality clinical policy and utilization management (UM) criteria, and effective coordination across internal teams and external stakeholders. The position serves as a central clinical authority supporting P&T and Formulary Value Committees (FVC), drug pipeline preparedness, therapeutic class strategy, and ongoing modernization of clinical criteria—balancing clinical quality, member access, affordability, and regulatory requirements. Other duties as assigned.

Requirements

Bachelor's degree in Pharmacy or PharmD required
5+ years of work experience in health plan pharmacy, PBM clinical management, or related clinical leadership role beyond degree
1+ years of leadership experience
Active Pharmacist license required
Eligibility to work in the US
Candidates must be legally authorized to work in the United States at the time of application.

Nice To Haves

Demonstrated experience with: Clinical policy and UM criteria development, P&T Committee support and presentations, Drug evaluations and therapeutic class reviews
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)
Leadership experience overseeing clinical pharmacists or matrixed teams
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

Establish and oversee clinical position strategy for all drug classes, including specialty, and emerging therapies
Ensure consistency, transparency, and evidence‑based rationale across formulary coverage, UM criteria, and clinical policy decisions
Provide governance oversight for clinical escalations, complex coverage questions, and exception resolution
Coordinate cross‑functional alignment between clinical pharmacy, UM operations, finance, actuarial, and PBM partner
Support governance forums by elevating issues, risks, and recommendations in a structured, decision‑ready format
Lead pipeline assessment and drug readiness activities for new molecular entities, biosimilars, expanded indications, and high impact therapies
Lead the development of presentation materials for P&T Committee and Formulary Value Committee (FVC) meetings, including: Drug evaluations and monographs, Therapeutic class reviews, Comparative effectiveness assessments, Financial and utilization considerations (in partnership with analytics/actuarial/finance)
Develop clear, defensible, evidence based recommendations to support committee decision making
Serve as a subject matter expert during committee discussions and executive escalations
Lead therapeutic class strategy reviews to ensure clinical positions remain current with evolving standards of care
Evaluate clinical evidence, treatment guidelines, real‑world data, and safety considerations
Identify opportunities for clinical optimization, standardization, and alignment across lines of business
Recommend updates to clinical positioning based on new evidence or utilization trends
Oversee custom policy writing for pharmacy and medical benefit drugs
Lead development and maintenance of UM clinical criteria, including prior authorization, step therapy, quantity limits, and coverage limitations
Conduct policy gap analyses to identify misalignment, outdated criteria, or regulatory risk
Ensure timely and clinically appropriate criteria updates, including: NF (Non Formulary) drug criteria, Newly approved therapies, Safety driven or guideline driven changes
Ensure policies and criteria are defensible, auditable, and aligned with regulatory and accreditation standards
Manage stakeholder relationships with internal and external partners
Communicate clinical strategy clearly to both clinical and non clinical audiences
Provide direction, mentorship, and clinical oversight for pharmacists and analysts supporting governance, policy, and P&T work
Coordinate workload, prioritization, and resource allocation to ensure timely delivery of clinical deliverables
Support knowledge development, standard work, and process improvement within the clinical governance function