Manager, Pharmacy Clinical Governance

Madison, WI, USA

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We’re a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration – because success is a team sport. It’s our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

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 (UM) criteria, and effective coordination across internal teams and external stakeholders.

The position serves as a central clinical authority supporting P&T and Formulary Value Committees (FVC), drug pipeline preparedness, therapeutic class strategy, and ongoing modernization of clinical criteria – balancing clinical quality, member access, affordability, and regulatory requirements. Other duties as assigned.

• 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
• Custom 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…