Director Clinical Affairs - Medicaid

Anticipated End Date:

2026-05-26

Position Title:

Director Clinical Affairs - Medicaid

Job Description:

Director Clinical Affairs - Medicaid

Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. 

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Director Clinical Affairs is responsible for Pharmacy & Therapeutics (P&T) Committee participation, driving Medicaid formulary strategy, and leading clinical process improvement initiatives specific to Medicaid lines of business. This role provides leadership and oversight for Medicaid formulary management, ensuring alignment with state-specific regulatory requirements, clinical policies, and cost-of-care strategies while maintaining operational excellence in formulary maintenance and compliance.

How you will make an impact:

• Represents the Medicaid line of business in P&T Committee discussions, providing subject matter expertise on formulary placement, tiering, and clinical policy alignment.

• Develops, maintains, and governs policies, processes, and procedures that support Medicaid formulary management and ensure compliance with state-specific requirements.

• Leads ongoing Medicaid formulary strategy, including weekly drug file updates, formulary maintenance, and decision-making aligned to existing clinical policies and regulatory mandates.

• Partners with internal stakeholders to communicate formulary decisions and ensure effective implementation with minimal disruption to members and plan operations.

• Supports evaluation, development, and implementation of cost-of-care strategies within Medicaid pharmacy programs, balancing clinical efficacy and financial performance.

• Collaborates with health plan partners to develop and maintain Medicaid formularies that meet state bid requirements and compliance standards.

• Identifies drugs or categories requiring escalation to the P&T Committee and ensures appropriate clinical review processes are followed.

• Documents current clinical and operational processes related to formulary management and evaluates opportunities for efficiency, accuracy, and compliance improvements.

• Oversees implementation of process improvements and measures outcomes, including operational efficiency, formulary accuracy, and regulatory compliance.

• Hires, trains, coaches, counsels, and evaluates performance of direct reports, leading a team responsible for Medicaid formulary operations.

Minimum Requirements:

Requires RPh and minimum of 6 years of managed care pharmacy experience within a health plan or pharmacy benefits management company; or any combination of education and experience, which would provide an equivalent background. Current license to practice pharmacy as an RPh in applicable state(s) required. Business planning, program and product development, project management, productivity initiatives, financial management of drug costs, formulary development, data analysis, and clinical intervention design and implementation experience required. Requires BA/BS in Pharmacy. 

Preferred Skills, Capabilities, and Experience:

• Deep experience in Medicaid managed care pharmacy, including formulary management, maintenance, and strong understanding of state-specific regulatory and compliance requirements preferred.

• Strong PBM experience with direct ownership of formulary strategy, drug file management, and decision-making preferred.

• Demonstrated experience supporting Pharmacy & Therapeutics (P&T) Committee processes,  as a clinical subject matter expert preferred.

• Proven leadership experience leading high-performing teams, with the ability to drive accountability for formulary accuracy, efficiency, and compliance preferred.

• Advanced knowledge of cost-of-care strategies and the ability to balance clinical outcomes with financial performance