Pharmacy Clinical Governance Manager

Job Summary

The Pharmacy Clinical Governance Manager is responsible for leading the development, maintenance, and oversight of the health plan’s enterprise clinical pharmacy positions across all drug classes and lines of business (Individual, Commercial, Medicare, and Medicaid). This role ensures consistent, evidence‑based clinical decision making through strong governance processes, high quality clinical policy and utilization management criteria, and effective coordination across internal teams and external stakeholders.

• Clinical Position Strategy & Governance
  • 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
• P&T/FVC Leadership & Drug Evaluation
  • Lead pipeline assessment and drug readiness activities for new molecular entities, biosimilars, expanded indications, and high impact therapies
  • Lead the development of presentation materials for P&T Committee and Formulary Value Committee (FVC) meetings, including:
    • Drug evaluations and monographs
    • Therapeutic class reviews
    • Comparative effectiveness assessments
    • Financial and utilization considerations (in partnership with analytics/actuarial/finance)
  • Develop clear, defensible, evidence based recommendations to support committee decision making
  • Serve as a subject matter expert during committee discussions and executive escalations
• Therapeutic Class Management
  • 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
• Utilization Management & Clinical Policy Development
  • 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

• 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

• Active Pharmacist license required

• 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…