Manager, Clinical Pharmacy
About the role
The Manager, Clinical Pharmacy role is critical in ensuring the health plan's enterprise clinical pharmacy positions are developed, maintained, and overseen consistently, transparently, and evidence-based. This role also involves leading the development, maintenance, and oversight of clinical policy and utilization management criteria, as well as coordinating with various internal and external stakeholders.
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.
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Conduct policy gap analyses to identify misalignment, outdated criteria, or regulatory risk.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.
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.
Preferred Qualifications
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
Benefits
The position offers a competitive salary range of $113,400 - $194,400, with a typical hiring range of $113,400 - $170,100. Additional benefits include:
Medical, dental, and vision insurance
PTO and holidays
Paid volunteer time off
401K contributions
caregiver services
Medica is an Equal Opportunity employer and offers a total rewards package that supports its employees.