Director, Pharmacy Management (Director IV)

CalOptima • Orange, California, United States • 1d ago

Director, Pharmacy Management (Director IV)

CalOptima

CalOptima Health is seeking a highly motivated Director, Pharmacy Management (Director IV) to join our team. The Director of Pharmacy will provide strategic leadership and operational oversight for all aspects of pharmacy services within a managed care organization, including Medi-Cal, OneCare (HMO SNP), and Covered California. The incumbent will be responsible for designing, implementing, and evaluating pharmacy benefit programs that align with clinical goals, financial sustainability, regulatory compliance, and member outcomes. The incumbent will lead 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. The incumbent 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. 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. The Director 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.

Position Information:

Department: Pharmacy Management
Salary Grade: 323 - $204,199 - $326,717 ($98.17 - $157.0756)
Work Arrangement: Full Office

Duties & Responsibilities:

50% - Leadership Responsibilities
Cultivates 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.
Develops and implements strategic pharmacy initiatives aligned with CalOptima Health's objectives and community mission.
Leads Pharmacy Benefit Managers (PBMs) contracting, implementation, oversight and vendor management, including contract negotiation, performance evaluation, and rebate management.
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.
Directs the Pharmacy team, including clinical pharmacists, pharmacy operations, and analytic staff, fostering a culture of excellence and innovation.
Serves in a Pharmacy and Therapeutics (P&T) Committee Leadership role.
Serves as pharmacy subject matter expert to the executive team and CalOptima Health's Board of Directors, including participation in the Pharmacy & Therapeutics (P&T) Committee.
Collaborates with leadership and staff in all relevant internal departments to share information and promote positive and collaborative business relationships with vendors and providers.
45% - Program Operations Oversight
Leads 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.
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.
Provides financial oversight, budget planning, and reporting for pharmacy benefit expenditures, ensuring transparency and fiscal responsibility.
Oversees pharmacy-related reporting requirements to regulators.
Manages audit preparation and corrective action plans in response to CMS, DHCS, and other regulatory bodies.
5% - Other
Completes other projects and duties as assigned.

Minimum Qualifications:

Doctor of Pharmacy (PharmD) PLUS 7 years of health plan experience in Medicare Part D and/or Medi-Cal required.
5 years of pharmacy management experience with implementation of commercial managed care products, such as products sold on state-based exchanges/Covered California.
3-4 years of progressive pharmacy leadership experience within a managed care, health plan, or PBM environment required.
Pharmacy Residency in Managed Care or Pharmacy Practice required.
Demonstrated success in directing and overseeing pharmacy benefit strategy, regulatory compliance, and PBM/vendor contracts required.
Experience with CMS audits, DHCS guidelines, and California Medicaid programs required.
Current knowledge and expertise in clinical pharmacology and disease states required.

Preferred Qualifications:

15 years of health plan and pharmacy experience in Medicare Part D and Medi-Cal.

Required Licensure / Certifications:

A current, valid, unrestricted California State Pharmacy License and Pharm.D.

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.
Ability to speak (enunciate) clearly in conversation and general communication.
Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.

If located at PACE:

Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.

If located in the Community:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.

About CalOptima Health:

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the 2025 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is August 13, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

To apply, please visit: https://jobs.caloptima.org/jobs/director-pharmacy-management-director-iv-505-city-parkway-west-california-united-states