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. Candidates must reside within commutable distance of that location or be 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. 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 model with clear decision rights, roles, escalation paths, documentation standards, and clinical committee interfaces that accelerates policy time to market by redesigning workflows, clarifying handoffs, identifying automation and AI opportunities, ensuring regulatory requirements, and confirming operational readiness with end-to-end accountability from evidence review through implementation and monitoring. Builds a forward-looking clinical strategy informed by the drug pipeline, emerging therapies, medical and specialty drug trends, clinical evidence, market dynamics, competitive intelligence, and current and future health-plan market needs that drives affordability and appropriate utilization through evidence-based coverage criteria, formulary and utilization-management strategies, site-of-care and medical-drug programs, biosimilar and therapeutic substitution opportunities, and high-value clinical interventions. Owns operational performance by establishing and monitoring meaningful KPIs, service levels, quality measures, productivity measures, policy-cycle metrics, prior authorization turnaround time, appeals outcomes, compliance indicators, and financial or utilization impact; uses data and insights to identify performance gaps, variation, trend drivers, and opportunities while developing action plans, removing barriers, and ensuring benefits and value are realized and sustained. Leads clinical and operational transformation across people, process, technology, data, and governance, including readiness planning, adoption, stabilization, and continuous improvement for new workflows, markets, products, systems, and vendor capabilities. Partners across Pharmacy, Medical Management, Legal, Compliance, Regulatory Affairs, Product, Sales, Finance, Actuarial, Technology, Analytics, Provider Operations, and health-plan teams to resolve clinical and operational tradeoffs, create enterprise-aligned solutions, and serve as a trusted advisor translating complex clinical, regulatory, operational, and financial issues into clear options, recommendations, decisions, and communication for senior leaders and governance bodies. Maintains regulatory, accreditation, mental health parity/NQTL, audit, and contractual readiness within scope of the function by ensuring policies, procedures, evidence, operational practices, and attestations are accurate, aligned, complete, and supported by appropriate controls. Provides oversight of delegated entities, PBM and other vendor-supported clinical functions by defining requirements, evaluating performance, resolving gaps, supporting contracting and implementation, and ensuring external capabilities align with enterprise standards and market needs. Creates scalable, market-responsive capabilities that support growth by aligning common clinical foundations while accommodating line-of-business, state, contractual, and brand-specific requirements when necessary; champions member- and provider-centered design by simplifying clinical review and authorization experiences, improving transparency and communication, and partnering on digital, electronic prior authorization, auto-approval, and claims-edit opportunities. Builds and develops a high-performing leadership and clinical team through clear priorities, role clarity, coaching, succession planning, performance management, professional development, and thoughtful workforce and capacity planning; fosters a culture of curiosity, accountability, psychological safety, evidence-based challenge, collaboration, innovation, and continuous improvement that empowers team members to make decisions at the appropriate level and learn through transformation. About Cambia Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through. Why Join the Cambia Team? At Cambia, you can: Work alongside diverse teams building cutting-edge solutions to transform health care. Earn a competitive salary and enjoy generous benefits while doing work that changes lives. Grow your career with a company committed to helping you succeed. Give back to your community by participating in Cambia-supported outreach programs. Connect with colleagues who share similar interests and backgrounds through our employee resource groups. We believe a career at Cambia is more than just a paycheck - and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more. In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include: Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits. Annual employer contribution to a health savings account. Generous paid time off varying by role and tenure in addition to 10 company-paid holidays. Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period). Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave). Award-winning wellness programs that reward you for participation. Employee Assistance Fund for those in need. Commute and parking benefits. 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. Equal Opportunity We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email View email address on click.appcast.io. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. #J-18808-Ljbffr Cambia Health