Hybrid Director, Clinical Ops & Medical Policy Leader

Cambia Health Solutions; Medford (OR); Hybrid; USD 179,000 - 243,000; Full time

Benefits offered by this job

Medical/dental/vision coverage

401(k) match

Paid time off

Parental leave

Remote work options

Job summary

Cambia Health Solutions in multiple Pacific Northwest locations seeks a Director of Clinical Operations and Medical Policy. You will guide clinical pharmacy services, med policy, prior authorization, and utilization management across commercial, Medicare, and Marketplace lines.

You will lead a team of managers, own budgets, and drive change, while ensuring compliance with CMS and state laws to improve member care and affordability.

Qualifications

• Bachelor's degree in Pharmacy or PharmD; residency or advanced degree preferred
• Minimum of five years of management or professional business experience in a managed health care system or related field
• Licensed pharmacist in state of practice

Responsibilities

• Lead clinical pharmacy services aligned with strategic goals and manage multi-billion drug expense across lines of business
• Provide vision and leadership to the Clinical Pharmacy Services team; oversee budgets and change management
• Direct formulary, policy, prior authorization, and utilization management across commercial/Medicare/Marketplace
• Oversee P&T Committee, MPG, and related governance; manage Medicare and QHP formularies
• Direct medication use programs to enhance value and reduce low-value therapies
• Collaborate across internal teams and with PBM to optimize programs for access, quality, and affordability
• Ensure ongoing evaluation and quality improvement of evidence-based medication assessment methods

Skills

Clinical pharmacy

Health care economics

Provider contracting

Communication

Project management

Medicare regulations

Pharmaceutical products knowledge

Coding/payments knowledge

Compliance (HIPAA)

AI in healthcare

Education

PharmD or BS in Pharmacy

Residency/advanced degree (preferred)

Job description

Cambia Health Solutions in multiple Pacific Northwest locations seeks a Director of Clinical Operations and Medical Policy. You will guide clinical pharmacy services, med policy, prior authorization, and utilization management across commercial, Medicare, and Marketplace lines.

You will lead a team of managers, own budgets, and drive change, while ensuring compliance with CMS and state laws to improve member care and affordability.