Manager, Clinical Pharmacy

About the role

The Manager, Clinical Pharmacy role is pivotal in ensuring the health plan's enterprise clinical pharmacy positions are developed, maintained, and overseen across various drug classes and lines of business. This role also involves leading P&T and FVC committees, evaluating new molecular entities, and managing therapeutic class strategy.

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• Conduct policy gap analyses to identify misalignment, outdated criteria, or regulatory risk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
• Oversight, escalation & stakeholder management
• Manage stakeholder relationships with internal and external partners
• Communicate clinical strategy clearly to both clinical and non-clinical audiences
• Team development & resource coordination
• 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

Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services, and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.