Clinical Operations Manager

Gainwell Technologies

Full-time - Mid Level

Professional, Scientific, and Technical Services

About the position

The Clinical Operations Manager is responsible for planning, directing, and coordinating the delivery of pharmacy benefit management (PBM) clinical services. This role ensures compliance with healthcare regulations while maintaining high standards of patient care. The manager leads initiatives to implement best practices in pharmacy benefit design, optimizing financial management and improving health outcomes for Medicaid individuals. The position involves managing relationships with internal stakeholders, data evaluation, and utilization management, while partnering with account and operations managers.

Responsibilities

• Provide clinical leadership for strategic and operational issues to drive performance and implement initiatives.
• Ensure clinical contract objectives are consistently met.
• Accountable for pharmacy and medical claim data mining and analysis to develop cost containment strategies.
• Analyze and report key pharmacy benefits metrics and success measures.
• Support the Drug Utilization Review (DUR) Committee.
• Be fully dedicated to ODM and available onsite at the ODM Columbus Office.
• Support and serve as back-up for the Account Manager and Clinical Pharmacist as appropriate.
• Oversee and implement quality improvement efforts to enhance value and cost-effectiveness.
• Accountable for all Preferred Drug List (PDL) and clinical reporting.
• Implement the PDL effectively.
• Support the Ohio Drug Utilization Review Committee, the Ohio Drug Utilization Review Board, and the Pharmacy & Therapeutics Committee.
• Monitor drug pipeline with emphasis on high-cost therapies.
• Make recommendations for improvements to meet customer expectations.
• Lead presentations to clients and conduct routine client visits.

Requirements

• Pharmacist degree (BS in Pharmacy or PharmD) and licensure required.
• Master's degree in Business or Healthcare Administration preferred.
• 3 or more years of managed care pharmacy or PBM operations leadership experience at the manager level required.
• Experience with pharmacy claims, clinical operations, medication pricing methodologies, NCPDP standards, financial management, and managed care statute.
• Experience evaluating healthcare data/outcomes is required.
• Strong presentation and communication skills required.
• Ability to manage various projects and teams simultaneously.
• Demonstrated record of improving operational efficiencies and financial performance.
• Excellent verbal and written skills.
• Understanding of State and Federal regulations and familiarity with accrediting organizations' requirements.
• Capable of interacting with medical specialties staff (MDs, Nurses, Care Coordinators, etc.) and Pharmacy Leadership.
• Strong acumen with establishing and monitoring clinical and business performance measures.
• Strong skills with Microsoft applications including Outlook, Word, Excel, PowerPoint, or Access.