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 in a Medicaid environment preferred.

• Exceptional communication and stakeholder management skills, with the ability to collaborate cross-functionally and represent Medicaid pharmacy strategy to senior leadership preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.