Director Clinical Operations and Medical Policy

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. Preference will be given to current employees and candidates who reside within a commutable distance from our Salt Lake City, Boise, Fargo and Lewiston offices or who are willing to relocate.   Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.    Who We Are Looking For:   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  provides strategic and operational leadership for pharmacy prior authorization, clinical review, appeals, formulary and medical drug policy governance, and related clinical operations across market for all lines of business. The role establishes a clear, scalable operating model that connects clinical decision-making with affordability, regulatory and accreditation expectations, operational excellence, and member and provider experience. As a strategic thought leader, the Director shapes the future state pharmacy clinical engine, anticipates market and drug-pipeline change, and converts enterprise priorities into executable roadmaps, measurable outcomes, and sustainable capabilities. As a transformational people leader, the Director builds a high-performing, inclusive team that is empowered to improve how work is done and deliver results through change. 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 thrive leading transformational change that connects clinical excellence with affordability, regulatory compliance, and exceptional member experience? Are you a strategic pharmacy leader who can build high-performing teams and turn enterprise priorities into measurable outcomes across complex health plan markets? Then this role may be the perfect fit.  What You Bring to Cambia:   Qualifications:    Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited school of pharmacy required; advanced degree in business, health administration, public health, or a related field preferred. Current pharmacist licensure in at least one U.S. jurisdiction, in good standing, required; ability to obtain additional licensure if required for assigned responsibilities. Eight or more years of experience in managed-care pharmacy, health-plan clinical operations, pharmacy benefit management, utilization management, medical policy, or a closely related environment. Five or more years of formal leadership experience, including responsibility for people, clinical or operational performance, and complex cross-functional initiatives; director-level or enterprise leadership experience preferred. Experience leading pharmacy clinical policy, prior authorization, appeals, specialty or medical-drug management, formulary governance, or related clinical operations across multiple products, markets, or lines of business strongly preferred. Equivalent combinations of education and relevant experience may be considered where permitted by organizational policy and applicable requirements Skills and Attributes:   Demonstrated strategic thinking and business acumen, with the ability to connect clinical, operational, financial, regulatory, member, provider, and market considerations and turn strategy into executable priorities. Proven people leadership, including coaching leaders and clinical professionals, setting clear expectations, building accountability, navigating ambiguity, developing talent, and leading through significant change. Deep knowledge of managed-care pharmacy clinical operations, including prior authorization, appeals, formulary and utilization management, evidence-based coverage policy, specialty and medical-benefit drugs, and clinical committee governance. Working knowledge of applicable federal and state regulatory requirements, accreditation expectations, parity/NQTL considerations, audit readiness, and delegated-function oversight in a health-plan or managed-care environment. Exceptional collaboration and influence skills, with the ability to align executives, clinical leaders, operators, legal and compliance partners, technologists, finance partners, vendors, and market stakeholders without relying solely on formal authority. Executive presence and excellent written, verbal, facilitation, and presentation skills; able to make complex information understandable, frame decisions, constructively challenge assumptions, and communicate with confidence and empathy. Ability to manage multiple interdependent priorities, make sound risk-based decisions, work independently, and maintain progress in a complex, highly regulated, matrixed environment. Demonstrated commitment to member and provider experience, clinical quality, affordability, ethical decision-making, inclusion, and a culture where teams can raise risks and improve the work. Demonstrated ability to leverage AI tools and resources to drive efficiency and innovation within area of expertise What You Will Do at Cambia: Provides vision, strategy, and accountable leadership for pharmacy clinical operations and medical policy, translating priorities into multi-year operating plans, annual goals, resource plans, and measurable business outcomes across an integrated portfolio that includes medical drug and pharmacy prior authorization, clinical coverage review, appeals and exceptions, continuation of therapy, formulary review, evidence evaluation, medication policy development and maintenance, and policy implementation. Establishes a disciplined, transparent policy-governance mode