Director, Clinical Operations & Medication Policy

Cambia Health Solutions; Renton (WA); Hybrid; USD 179,000 - 243,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

401(k) with match

Job summary

Cambia Health Solutions in Renton, WA is seeking a Director of Clinical Operations and Medical Policy to lead clinical pharmacy services and shape policy and formulary strategy. The role drives evidence-based medication use, prior authorization, and utilization management across multiple benefit types, ensuring alignment with CMS and state regulations.

The leader will guide a team of managers, oversee budgets, and collaborate with internal departments and external vendors to optimize access,

Qualifications

• Bachelor's degree in Pharmacy or PharmD; Residency certificate or advanced degree preferred
• Minimum of five years of management or professional business experience in a managed health care system, medical group, hospital, or related business in health care delivery industry or an equivalent combination of education and experience
• Licensed pharmacist in state of practice

Responsibilities

• Lead and direct clinical pharmacy services that align with organizational strategic goals, managing nearly $2B of annual drug expense across all lines of business while ensuring compliance with state, federal, and CMS regulations
• Provide vision, direction, and leadership to Clinical Pharmacy Services team of managers and staff, overseeing work activities, developing budgets, and implementing change management plans to achieve strategic objectives
• Direct pharmacy formulary, medication policy, prior authorization, and utilization management activities for commercial, Medicare, and Health Insurance Marketplace lines of business, including product review, market analysis, coverage guidelines development, and clinical support of the pharmacy appeal process
• Be accountable for the Pharmacy and Therapeutics (P&T) Committee, Medication Policy Group (MPG), Pharmacy Business Committee and related governance committees, while managing development, maintenance, and submission of Medicare and QHP formularies
• Direct and oversee medication use programs to encourage best value medications and discourage unsafe or low clinical value medications, including medication pipeline management and strategies to manage pharmacy trend drivers
• Collaborate internally across departmental teams (customer services, provider relations, sales/marketing, operations, medical services, contracting/rebates, analytics) and externally with healthcare professionals and key vendors including the Pharmacy Benefit Manager (PBM) to optimize programs supporting medication access, quality, and affordability
• Ensure ongoing evaluation and quality improvement of evidence-based medication technology assessment methods, develop performance metrics with routine reporting and analysis, coordinate resources to address clinical pharmacy issues, and contribute to corporate quality initiatives through process improvement teams
• You bring unique value to our community of 200 leaders running our company. By actively engaging with your peers and inspiring your teams, you play an essential role in making health care easier and lives better.

Skills

Pharmacy leadership

Clinical pharmacy

Health economics

Policy development

Communication skills

Education

Pharmacy degree or PharmD

Residency or advanced degreePreferred

Job description

Cambia Health Solutions in Renton, WA is seeking a Director of Clinical Operations and Medical Policy to lead clinical pharmacy services and shape policy and formulary strategy. The role drives evidence-based medication use, prior authorization, and utilization management across multiple benefit types, ensuring alignment with CMS and state regulations.

The leader will guide a team of managers, oversee budgets, and collaborate with internal departments and external vendors to optimize access,