Clinical Pharmacist IV - Regulatory

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 Clinical Pharmacist – Regulatory is responsible for supporting Pharmacy department oversight for state and federal clinical requirements and compliance. Oversight is supported through reporting, requirements review and interpretation, and audit activities. This position also provides oversight of delegated clinical activities for pharmacy and medical pharmacy reviews. Additional responsibilities include performing internal clinical reviews, both initial and appeals, for select Medicare, Medicaid and Commercial/IFB cases.

This role will require collaboration with other departments, regulators, and other external parties to ensure regulatory compliance for pharmacy services. Performs other duties as assigned.

• Review and interpret new regulatory guidance (e.g., HPMS memos, statutes) and its applicability to Medica pharmacy processes. Ensure Medica is prepared to meet new regulatory requirements by communicated deadlines.
• Support Medica’s Pharmacy department in responding to regulatory audits and compliance inquiries. Support end-to-end resolution of audit and compliance items from engagement to corrective action plan completion. Coordinate and assist in responses to pharmacy regulatory audits with internal Government Relations and Compliance departments.
• Support required regulatory submissions for all regulators.
• Provide clinical pharmacy support for NCQA initiatives, projects, and audits.
• Develop and maintain Policies and Procedures related to pharmacy regulatory processes.

• Oversee clinical review activities delegated to PBM and Medical Drug Vendor.
• Provide oversight of clinical services and programs delegated to PBM and medical drug vendor.
• Assist with audits and other regulatory activities with pharmacy delegate impacts.
• Oversee monitoring activities and reporting to ensure appropriate compliance with regulatory requirements and specific clinical initiatives.
• Evaluate the pharmacy and medical pharmacy benefits to ensure regulatory compliance.
• Identify opportunities for clinical monitoring programs and support the maintenance of existing monitoring initiatives.

• Perform internal clinical reviews, both initial and appeals, for select Medicare, Medicaid and Commercial/IFB cases.
• Assist with identifying and recommending efficiencies for clinical review processes including coverage criteria and denial language.
• Compliance with applicable federal and state rules and regulations, guidance, and statutes for all lines of business while completing clinical reviews.
• Provide support to operational teams on various requests including resolving clinical pharmacy-related inquiries from members, providers, and/or pharmacies.

• Bachelor of Science in Pharmacy or PharmD required
• 5+ years of experience in health plan pharmacy, PBM clinical management, or related clinical leadership role beyond degree

• Demonstrated experience with:
  • Familiarity with the clinical review process for prior authorization requests
  • Health plan delegate…