Design, build and own comprehensive clinical programs (e.g., GLP-1 weight loss management, opioid management, fraud/waste/abuse detection)
Define clinical policy and intent behind prior authorization criteria and utilization management controls
Serve as the internal clinical authority and point of contact for complex clinical questions and policy decisions
Translate clinical guidelines and evidence into actionable interventions that balance member access with cost management
Design, implement, and maintain drug formularies that balance clinical efficacy, safety, and cost-effectiveness with lowest net cost strategies
Conduct therapeutic class reviews and drug evaluations using evidence-based clinical criteria
Manage formulary updates in response to new drug approvals, pipeline changes, and evolving clinical evidence
Develop and manage PA criteria that are clinically sound, medication-specific, and operationally effective
Lead Formulary Navigator buildout and drive automation of drug list processes
Partner with Analytics team on targeting logic, intervention design, and performance dashboards
Support client-facing clinical discussions and explain coverage rationale with clinical credibility

PharmD from an ACPE-accredited college of pharmacy
Active pharmacist license
Minimum 5 years of PBM experience with demonstrated expertise in formulary management and utilization management
Proven track record of designing and implementing clinical programs with measurable outcomes
Strong understanding of pharmacy benefit design, drug utilization management, and clinical guidelines
Experience with specialty pharmaceuticals, biosimilars, and limited distribution drugs
Knowledge of rebate compliance, contracting, and lowest net cost strategies
Proficiency with pharmacy claims adjudication platforms and NCPDP standards
Experience translating vendor clinical criteria into operational logic
Advanced analytical skills with ability to interpret claims data and identify trends
Excellent project management capabilities with ability to manage multiple priorities

Director, Clinical Services

Key skills