Cambia Health Solutions

Director Clinical Operations and Medical Policy

Cambia Health Solutions • $168K — $275K *
Portland, OR 97229In-Person
Healthcare
5 - 7 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Bachelor's degree in Pharmacy or PharmD; advanced degree preferred
  • Minimum five years in management or professional roles in healthcare delivery
  • Licensed pharmacist in state of practice
  • Strong clinical pharmacy background and clinical therapy skills
  • In-depth knowledge of health care economics, financing, and provider contracting
  • Excellent communication, analytical, and project management skills

Responsibilities

  • Lead clinical pharmacy services to manage $2B annual drug expense
  • Provide direction and leadership to Clinical Pharmacy Services team
  • Oversee pharmacy formulary and utilization management for various lines of business
  • Accountable for the Pharmacy and Therapeutics (P&T) Committee and related governance
  • Direct medication use programs to manage pharmacy trend drivers
  • Collaborate across departments and with external healthcare professionals
  • Evaluate and improve evidence-based medication assessment methods

Benefits

  • Flexible work options including hybrid schedule
  • Comprehensive health and wellness benefits
  • Professional development opportunities
  • Employee engagement programs
  • Supportive team environment focused on making healthcare better
Full Job Description
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.

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 health care industry practices, such as DOLI, PPACA and HIPAA
  • Demonstrated ability to leverage AI tools and resources to drive efficiency and innovation within area of expertise


What You Will Do at Cambia:

  • Lead and direct clinical pharmacy services that align with organizational strategic goals, managing nearly $2B of annual drug expense across all lines of business while ensuring compliance with state, federal, and CMS regulations
  • Provide vision, direction, and leadership to Clinical Pharmacy Services team of managers and staff, overseeing work activities, developing budgets, and implementing change management plans to achieve strategic objectives
  • Direct pharmacy formulary, medication policy, prior authorization, and utilization management activities for commercial, Medicare, and Health Insurance Marketplace lines of business, including product review, market analysis, coverage guidelines development, and clinical support of the pharmacy appeal process
  • Be accountable for the Pharmacy and Therapeutics (P&T) Committee, Medication Policy Group (MPG), Pharmacy Business Committee and related governance committees, while managing development, maintenance, and submission of Medicare and QHP formularies
  • Direct and oversee medication use programs to encourage best value medications and discourage unsafe or low clinical value medications, including medication pipeline management and strategies to manage pharmacy trend drivers
  • Collaborate internally across departmental teams (customer services, provider relations, sales/marketing, operations, medical services, contracting/rebates, analytics) and externally with healthcare professionals and key vendors including the Pharmacy Benefit Manager (PBM) to optimize programs supporting medication access, quality, and affordability
  • Ensure ongoing evaluation and quality improvement of evidence-based medication technology assessment methods, develop performance metrics with routine reporting and analysis, coordinate resources to address clinical pharmacy issues, and contribute to corporate quality initiatives through process improvement teams
  • You bring unique value to our community of 200 leaders running our company. By actively engaging with your peers and inspiring your teams, you play an essential role in making health care easier and lives better.


#LI-Hybrid

Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.
  • Oregon, Washington, Utah, and Idaho: The expected hiring range is $179,400 - $242,700, the full salary range is $168,000 - $275,000 and the bonus target is 25%.
  • North Dakota: The expected hiring range is $166,991.85 - $225,930.15, the full salary range is $148,272 - $244,650 and the bonus target is 20%.


Learn more about our benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.

As part of our security requirements, new hires will need access to a personal mobile device to set up Multi-Factor Authentication (MFA) upon joining the company. MFA is an important layer of protection for accessing Cambia systems and is required for all employees.

About Cambia Health Solutions

Cambia Health Solutions is a nonprofit healthcare company that provides health insurance, healthcare services, and technology solutions to individuals and organizations. The company was founded in 1917 and is headquartered in Portland, Oregon. Cambia Health Solutions operates in several states, including Oregon, Washington, Idaho, and Utah. The company's subsidiaries include Regence BlueCross BlueShield, BridgeSpan Health, and Asuris Northwest Health. Cambia Health Solutions is committed to improving the health and well-being of its members, and has received numerous awards for its innovative solutions.
Learn more about Cambia Health Solutions
Size
5,000 employees
Industry
Healthcare
Founded
1996
* Ladders Estimates

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