Sr Director, Pharmacy Management

Sr Director, Pharmacy ManagementCalOptimaJoin Us in this Amazing OpportunityThe Team You'll JoinWe are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.More About the OpportunityWe are hoping you will join us as aSr Director, Pharmacy Managementand help shape the future of healthcare where you'll be an integral part of ourPharmacy Managementteam, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. Under the direction of the CMO, you will be responsible for strategic planning and leadership, regulatory compliance, and management as well as operational oversight for all aspects of pharmacy services within a managed care organization, including Medi-Cal, Medicare Advantage Part D (HMO D-SNP), and Covered California. You will also be responsible for designing, implementing, and evaluating pharmacy benefit programs that align with clinical goals, financial sustainability, regulatory compliance, and member outcomes. You will develop and direct formulary strategy, utilization management, quality initiatives, and vendor performance-including Pharmacy Benefit Manager (PBM) oversight-and serves as the organization's principal pharmacy advisor to executive leadership and the Board of Directors. You will ensure compliance with Centers for Medicare & Medicaid Services (CMS), state Medicaid, Covered California, Department of Managed Health Care (DMHC), and National Committee for Quality Assurance (NCQA) standards while advancing initiatives to improve population health, medication adherence, and cost-effective drug use. You will be accountable for pharmacy-related quality programs and will contribute to the improvement of CalOptima Health's quality performance including but not limited to Star ratings.This position will require a dynamic, data-driven leader with extensive experience in managed care pharmacy, cross-functional collaboration, and a strong understanding of the regulatory environment governing Medicare, Medicaid, and commercial health plans. You will ensure alignment with CalOptima Health's mission to serve member health with excellence and dignity, respecting the value and needs of each person through collaboration with our providers, community partners and local stakeholders. Together, we are building a stronger, more equitable health system.Your Contributions To the Team: 60% - Leadership ResponsibilitiesCultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Directs and oversees the Pharmacy department in carrying out all department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals and priorities. Leads, develops, and implements pharmacy business plan and strategic initiatives in alignment with CalOptima Health's objectives and community mission, while taking ownership of both short- and long-term direction of the department. Supports CalOptima Health's quality goals by driving improvements in Covered California Quality Transformation Initiative, Star Ratings, Pharmacy Quality Alliance (PQA) adherence measures, Healthcare Effectiveness Data and Information Set (HEDIS) outcomes, and other not yet identified quality programs. Delivers effective service management through the definition and adoption of a governance practice that uses key performance indicators (KPIs) and metrics to track and measure the quality of service. Continually monitors metrics and the integration of them with key accountabilities to ensure consistency of approach and continual service improvement. Oversees and ensures pharmacy management operational compliance with organizational standards, policies and procedures, and regulatory requirements while maintaining knowledge of related changes and developing effective communication plans as needed. Serves as pharmacy subject matter expert to the executive team and CalOptima Health's Board of Directors. Directs all aspects of running an efficient Pharmacy team, including hiring, supervising, coaching, developing, disciplining, motivating as well as attracting and retaining a high-performing team that achieves department goals that are in alignment with the CalOptima Health Strategic Plan. Develops, implements, and upholds departmental policies and procedures. Collaborates with CMO to develop and monitor annual budgets and corresponding business cases to ensure utilization meets strategic, operational, and budgetary goals. Collaborates with CMO to manage staffing model and succession planning, and monitors related resource allocation for the department. Collaborates with CMO and other senior leaders to develop projections for future year utilization and cost trends. Supports senior leadership within CalOptima Health to drive and lead changes by communicating goals clearly and developing relationships with key stakeholders. Serves in a Pharmacy and Therapeutics (P&T) Committee Leadership role. Collaborates with leadership and staff across internal departments to share information, support organization goals, and promote positive and collaborative business relationships with vendors and providers.35% - Program Operations OversightLeads and manages all pharmacy-related operational and clinical functions, including but not limited to formulary development, prior authorization protocols, and utilization management for Medi-Cal, Medicare, and Covered California lines of business as appropriate. Directs the Pharmacy team, including clinical pharmacists, pharmacy operations, and analytic staff, fostering a culture of continuous improvement, excellence and innovation, and promotes collaboration between the Pharmacy team and other internal departments and external providers. Oversees new program development related to pharmacy, including overseeing new program design and implementation for the Covered California line of business. Collaborates with internal departments (Medical Management, Quality, Compliance, Finance, line-of business leaders, etc.) to optimize member outcomes and drug cost-effectiveness. Ensures compliance with state and federal regulations, including CMS, DMHC, Covered California, and Medi-Cal Rx. Leads Pharmacy Benefit Manager (PBM) procurement, contracting, implementation, oversight and vendor management, including contract negotiation, performance evaluation, and rebate management. PBM oversight is a critical requirement of this role including real time oversight of PBM Point of Service prescription fulfillment. Collaborates with CMO to provide financial oversight, budget planning, and reporting for pharmacy benefit expenditures, ensuring transparency and fiscal responsibility.

Created: 2025-12-03