Director Clinical Operations and Medical Policy

## Director Clinical Operations and Medical Policy Apply locations:
Fargo, ND:
Salt Lake City, UT:
Renton, WA:
Medford, OR:
Portland, ORtime type:
Full time posted on:
Posted Yesterday job requisition :
R-6760
** Director Clinical Operations and Medical Policy
**** Hybrid role (3 days/week in office) at our Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston, Fargo offices.
**** Candidates must reside within commutable distance of that location or be willing to relocate.
**** Build a career with purpose. Join our*
* ** Cause*
* ** to create a person-focused and economically sustainable health care system.*
* ** Who We Are Looking For:
** Every day, Cambia’s dedicated team of Pharmacy leaders are living our mission to make health care easier and lives better. As a member of the Pharmacy Services leadership team, our Director Clinical Operations and Medical Policy develops strategy, directs, and oversees clinical pharmacy activities and services. These activities include services pertaining to: evidence reviews of medications, formulary development, Pharmacy and Therapeutics (P&T) Committee support, medication use policy development, the Medication Policy Group (MPG), clinical prior authorization, implementation of utilization management activities, guidance for clinical edit coding for prescription claims processor or medical claims system, medication pipeline monitoring, medication trend management, and consultation and guidance on medication-related issues.

The scope includes medications covered under the pharmacy benefit, medical benefit and specialty medications – all in service of creating a person-focused health care experience.

As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us.

Do you want to lead a team that bridges clinical pharmacy expertise with health policy development, overseeing everything from P&T Committee support to utilization management in a mission-driven organization? Are you looking for an opportunity to drive clinical pharmacy innovation where your strategic leadership in medication policy, prior authorization, and formulary management creates meaningful impact for members across multiple benefit types?

Then this role may be the perfect fit.
** What You Bring to Cambia:*
* *
* Qualifications:

*
* * Bachelor's degree in Pharmacy or PharmD;
Residency certificate or advanced degree in health care administration, economics, public health, pharmacy administration, finance, or equivalent field 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
** Skills and Attributes:*
* * Demonstrated strong clinical pharmacy background with ability to demonstrate clinical therapy skills and knowledge
* Demonstrated strong knowledge of health care economics and financing; health care industry dynamics; and provider contracting strategies, techniques, and processes
* Demonstrated success in managing professional business relationships in a managed care system, medical group, hospital, or related business in health care delivery industry
* Excellent verbal and written communication skills; strong business analytical skills and abilities; strong project management and coordination ability; ability to function effectively as a management team member
* Demonstrated knowledge of the following:
Health Plan and benefit design structures and application;
Medicare/CMS regulations and applicability in administering the Medicare Product;
Pharmaceutical products, including orals, injectables, infusion products, and chemotherapy;
Knowledge of health care coding and payment systems (such as ICD-10, CPT, HCPCS, NDC);
Compliance related activities, legislative and regulatory activities, health insurance operations, or legal research helpful; state and federal laws and rules regarding the practice of pharmacy and regulation of…