Director of Clinical Services (MUST HAVE 5+ YEARS OF PBM EXPERIENCE)

Position Summary

The Director of Clinical Services oversees the daily operations, strategic direction, and quality of DisclosedRx's Pharmacy Benefit Management (PBM) clinical programs. This role leads and develops the clinical team while ensuring excellence in utilization management, formulary strategy, prior authorization reviews, clinical criteria development, and clinical program implementation. The Clinical Department Manager serves as the primary clinical resource for internal teams, clients, prescribers, and members, ensuring accuracy, compliance, and efficiency across all clinical functions.

Job Responsibilities

To perform this job successfully, an individual must be able to perform each essential function satisfactorily.

• Leads and manages the daily operations of the Clinical Department, providing coaching, feedback, and performance monitoring for clinical staff.
• Oversees prior authorization (PA) reviews, appeals, and clinical case escalations to ensure timely, consistent, and clinically sound determinations.
• Creates, maintains, and updates clinical criteria, PA guidelines, step therapy protocols, and formulary documentation.
• Oversees formulary management including exclusions, tiering, biosimilar strategy, and specialty drug oversight.
• Reviews and analyzes clinical studies, guidelines, drug pipeline information, and utilization data to support decision-making and policy updates.
• Supports preparation for and participation in Pharmacy & Therapeutics (P&T) Committee processes.
• Ensures compliance with state regulations, URAC standards (if applicable), and internal clinical quality guidelines.
• Serves as the clinical escalation point for employer groups, consultants, prescribers, pharmacies, and internal departments.
• Develops and delivers clinical education to internal teams, including training on PA criteria, utilization management workflows, and formulary operations.
• Builds and maintains program catalogues and clinical documentation repositories.
• Provides clinical insights during client implementations, renewals, and trend reviews.
• Monitors key performance indicators (KPIs) for clinical operations and identifies improvement opportunities.
• Collaborates with leadership to enhance clinical workflows, implement automation, and improve efficiency and accuracy.
• Performs other duties as assigned or requested. Any one position may not include all the duties listed; these duties represent the key responsibilities typically associated with this role.

Required Experience

Preferred Qualifications :