Salary range $150,000 -170,000 DOE
Bonus up to 8% potential of annual salary (prorated depending on start date as we are 6 months into this fiscal year already)
Annual merit increases of 4% max when exceeding expectations
Job Title: Clinical Pharmacy Manager
Department: Medical Management
Position Type: Full-Time
Classification: Exempt
Travel: Occasional travel may be required of this position.
Summary Description:
The Clinical Pharmacy Manager reports directly to the Pharmacy Director. In this role, the Clinical Pharmacy Manager
provides clinical supervision and operational leadership and support alongside the Pharmacy Director to a team of
Clinical Pharmacists, Pharmacy Technicians and clerical staff to administer a compliant pharmacy department including,
utilization management (UM) program across all lines of business. The Clinical Pharmacy Manager will ensure regulatory
compliance, timely and effective application of UM criteria in accordance with departmental standards, pharmacy laws
and regulations. The Clinical Pharmacy Manager will work with the Pharmacy Director to develop workflows, build key
performance indicators, oversee daily operations including coverage for all holiday and weekend work, ensure timely
and accurate execution, troubleshoot and identify root cause when issues arise, as well as train and coach the team of
reviewers. The Clinical Pharmacy Manager will play a critical role in managing Medicare line of business, supporting WHA
Pharmacy and Therapeutics Committee (P&T) and formulary management. Clinical Pharmacy Manager will support
strategic initiatives specifically moving from current state formulary management to future state processes.
Representative Duties: Please note this job description is not designed to cover or contain a comprehensive listing of
activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities
may change at any time with or without notice.
• Promote and adhere to our Privacy and Information Security Programs. Ensure and verify that all department
Workforce Members attend and complete mandatory training. Inform department Workforce Members that we
will take disciplinary action up to and including termination of employment or assignment with for violation
of these privacy and security policies, procedures, and regulatory requirements. Also, that strict adherence to the
related laws, rules, regulations, policies, and procedures is considered an integral part of their job performance,
and monitor compliance.
• Support functional area Chief and/or Director with the development and implementation of the organizational
plans, strategies and annual budget.
• Review and analyze the functional area and/or department actual performance against the targeted performance
objectives leveraging company data applicable to the department, available KPI (Key-Performance Reports) and
other available performance measurement resources.
• Work collaboratively and cooperatively with functional area leaders to develop and implement supplemental plans
and/or strategies to mitigate departmental performance gaps to stated business objectives and/or targeted KPI
(Key Performance Indicator) results.
• Support the functional area Chief and/or Director with the process of aligning and documenting the department’s
business priorities, goals and objectives on a quarterly and/or monthly basis so as to achieve business targets as
set forth in the annual business plan.
• Interface and collaborate with departmental team members, as well as other functional area leaders, on special
projects and/or towards the accomplishment of company-wide business goals, objectives and project deliverables.
• Represent and effectively present functional area and/or departmental performance information, project updates
and other miscellaneous information to a variety of internal and/or external organizations, business clients,
consumers and/or the general public.
• Support functional area Chief and/or Director with the development and maintenance of key-stakeholder
relationships relevant to the department and/or the company.
• Collaborate with functional area leaders on the departmental staffing plans and processes to support the effective
execution of the departments and/or company’s business plans, strategies and initiatives.
• Work collaboratively with Human Resources and the functional area team members to select, train, supervise, and
effectively performance manage the department’s staff.
• Maintain consistently high-performance standards for all direct reports and other team members by regularly
communicating business updates, coaching, counseling, disciplining and completing timely performance
evaluations in accordance with the company’s Human Resources guidelines and standards.
Job Description
• Establish and execute personal and professional development initiatives for direct reports and other team
members and their self for the purpose of keeping current and effective in the performance of their various job
duties and roles.
• Serve as the primary SME and point of contact for day-to-day activities under the Pharmacy department for both
PA and Appeals and Grievances (pharmacy), Sales, Member Services or other departments within
• Provide direct oversight of the PA and A&G support for clinical services including providing direction to
Pharmacy staff and other departments
• Support clinical programs and quality auditing under the CMO and Pharmacy Director
• Develop and update clinical criteria for review of medications
• Responsible for annual inter-rater reliability testing to ensure quality control amongst all pharmacy UM/A&G
reviewers
• Work with the Pharmacy Director to ensure there is adequate staffing and coverage to manage volume of
reviews, taking seasonality, holiday/weekend coverage into consideration by line of business while ensuring
turnaround times are accounted for
• Help review regulatory changes, support in Pharmacy/UM audits and any quality reviews
• Main point of contact for regulatory changes related to the Pharmacy department from state/federal agencies
including DMHC, NCQA or CMS
• Monitor and review prior authorization requestsfor medications, perform duties related to drug utilization
reviewand support internal departments with clinical calls requiring pharmacist intervention.
• Research drug information to maintain drug knowledge and disease state understanding for application to
prior authorization reviews.
• Main point of contact for supporting, maintaining and providing leadership guidance for maintaining PA
processing platform
• Responsible for managing, leading and providing strategic guidance for all clinical initiatives within the
Pharmacy department, specifically, helping with migration from custom formulary to standard PBM
formulary
• Will be responsible for SERF filing, CMS BID support and other annual submissions to regulating bodies
• Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols,
programs,and guidelines for all lines of business from the PBM partner
• Provide support to the P&T Committee through committee participation and project completion, including
therapeutic category, drug reviews, and analysis as needed.
• Participate in the development and implementation of clinical quality improvement programs, working closely
with the Medical Management department, PBM, and Medical Groups.
• Interface with Medical Groups and Prescribers to educate and inform them of pharmacy program initiatives
and cost-effective prescribing options.
• Help support and lead initiative conversations with our medical group partners during our quarterly joint
operating committee meetings
• Provide clinical guidance and support to various departments and address clinical related questions.
• Perform other duties and special projects as assigned by the Pharmacy Director or Chief Medical Officer.
Job Description
Qualifications: Any combination of education and experience that would likely provide the required knowledge and
abilities is qualifying. A typical way to obtain the knowledge and abilities would be:
• PharmD. or equivalent, completion of a managed care residency or advanced degree preferred.
• Must have valid California Pharmacist license with no restriction and must be maintained.
• 5 years’ managed care pharmacy experience, PBM, Health Plan, or delegated Medical Group with increasing
responsibilities including supervisory preferred.
• 2 years’ experience supporting Medicare formulary management, prior authorization is preferred.
• Must have a deep understanding and experience for state and federal regulations. Background in HEDIS, NCQA,
DMHC, CMS, Knoxx-Knee, STARS programs is preferred.
• Proficient in drug literature and clinical trial evaluation, including proficiency with electronic pharmacy
compendia such as (e.g. Micromedex, Clinical Pharmacology, NCCN) is highly preferred.
• Strong clinical and analytical background on specialty medications.
• Experience writing drug monographs and/or prior authorization criteria.
• Formulary management experience preferred.
• Proficient computer skills, including electronic mail, routine database activity, word processing, spreadsheet,
graphics, etc.
• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
Physical Demands: The conditions herein are representative of those that must be met by an employee to successfully
perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential job functions.
While performing the duties of this job, the employee may occasionally be required to stand; walk; sit; use hands to
grasp, handle, or feel objects; reach with hands and arms; balance; stoop, kneel, crouch or crawl; talk or hear. The
employee may occasionally lift or move up to 10 pounds.
Competency Levels: Competencies and the proficiency levels are based on HRSG’s Competency Model and are located
on Intranet under Human Resources.
Level Competencies
3 Communication 2 Integrity
2 Customer Service 3 Quality Focus
3 Decision Making 3 Improving Business Processes
3 Detail Orientation, Analysis and Logic 2 Team Leadership
3 Initiative 3 Time Management/Priority Setting
Disclaimer:
I have read thisjob description and I understand all my job duties and responsibilities. I a
