Clinical Pharmacist IV - Regulatory

Job Description

Job Description

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Clinical Pharmacist – Regulatory is responsible for supporting Pharmacy department oversight for state and federal clinical requirements and compliance. Oversight is supported through reporting, requirements review and interpretation, and audit activities. This position also provides oversight of delegated clinical activities for pharmacy and medical pharmacy reviews. Additional responsibilities include performing internal clinical reviews, both initial and appeals, for select Medicare, Medicaid and Commercial/IFB cases. This role will require collaboration with other departments, regulators, and other external parties to ensure regulatory compliance for pharmacy services. Performs other duties as assigned.

Key Accountabilities 

Regulatory Oversight

• Review and interpret new regulatory guidance (e.g., HPMS memos, statutes) and its applicability to Medica pharmacy processes. Ensure Medica is prepared to meet new regulatory requirements by communicated deadlines.
• Support Medica’s Pharmacy department in responding to regulatory audits and compliance inquiries. Support end-to-end resolution of audit and compliance items from engagement to corrective action plan completion. Coordinate and assist in responses to pharmacy regulatory audits with internal Government Relations and Compliance departments.
• Support required regulatory submissions for all regulators.
• Provide clinical pharmacy support for NCQA initiatives, projects, and audits.
• Develop and maintain Policies and Procedures related to pharmacy regulatory processes.

Delegate Oversight

• Oversee clinical review activities delegated to PBM and Medical Drug Vendor.
• Provide oversight of clinical services and programs delegated to PBM and medical drug vendor.
• Assist with audits and other regulatory activities with pharmacy delegate impacts.
• Oversee monitoring activities and reporting to ensure appropriate compliance with regulatory requirements and specific clinical initiatives.
• Evaluate the pharmacy and medical pharmacy benefits to ensure regulatory compliance.
• Identify opportunities for clinical monitoring programs and support the maintenance of existing monitoring initiatives.

Clinical Case Reviews

• Perform internal clinical reviews, both initial and appeals, for select Medicare, Medicaid and Commercial/IFB cases.
• Assist with identifying and recommending efficiencies for clinical review processes including coverage criteria and denial language.
• Compliance with applicable federal and state rules and regulations, guidance, and statutes for all lines of business while completing clinical reviews.
• Provide support to operational teams on various requests including resolving clinical pharmacy-related inquiries from members, providers, and/or pharmacies.

Required Qualifications 

• Bachelor of Science in Pharmacy or PharmD required
• 5+ years of experience in health plan pharmacy, PBM clinical management, or related clinical leadership role beyond degree

Required Certifications/Licensure

• Active Pharmacist license required 

Preferred Qualifications 

• Demonstrated experience with:
  • Familiarity with the clinical review process for prior authorization requests
  • Health plan delegate oversight
  • Audit and compliance activities
• Experience working within regulated environments (Medicare and/or Medicaid
• Board certification (e.g., BCPS or other relevant specialty)
• Experience in plan led or hybrid PBM models
• Familiarity with accreditation and regulatory frameworks (e.g., CMS, NCQA)
• Clinical credibility and sound judgment
• Strong governance mindset and attention to consistency
• Ability to translate evidence into practical, defensible clinical positions
• Executive level presentation and communication skills
• Collaborative, cross functional leadership

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, St. Louis, MO, or Omaha, NE. 

The full salary grade for this position is $113,400 - $194,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $113,400 - $170,100. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.  In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. 

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.