Utilization Manager Jobs in Wisconsin (NOW HIRING)

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Clinical Pharmacy Manager, Formulary Strategy is responsible for leading the development, maintenance, and oversight of the health plan’s enterprise clinical pharmacy positions across all drug classes and lines of business (Individual, Commercial, Medicare, and Medicaid). This role ensures consistent, evidence based clinical decision making through strong governance processes, high quality clinical policy and utilization management (UM) criteria, and effective coordination across internal teams and external stakeholders.

The position serves as a central clinical authority supporting P&T and Formulary Value Committees (FVC), drug pipeline preparedness, therapeutic class strategy, and ongoing modernization of clinical criteria—balancing clinical quality, member access, affordability, and regulatory requirements. Other duties as assigned.

Key Accountabilities

• Clinical Position Strategy & Governance
  • Establish and oversee clinical position strategy for all drug classes, including specialty, and emerging therapies
  • Ensure consistency, transparency, and evidence‑based rationale across formulary coverage, UM criteria, and clinical policy decisions
  • Provide governance oversight for clinical escalations, complex coverage questions, and exception resolution
  • Coordinate cross‑functional alignment between clinical pharmacy, UM operations, finance, actuarial, and PBM partner
  • Support governance forums by elevating issues, risks, and recommendations in a structured, decision‑ready format

• P&T/FVC Leadership & Drug Evaluation
  • Lead pipeline assessment and drug readiness activities for new molecular entities, biosimilars, expanded indications, and high impact therapies
  • Lead the development of presentation materials for P&T Committee and Formulary Value Committee (FVC) meetings, including:
    • Drug evaluations and monographs
    • Therapeutic class reviews
    • Comparative effectiveness assessments
    • Financial and utilization considerations (in partnership with analytics/actuarial/finance)
  • Develop clear, defensible, evidence based recommendations to support committee decision making
  • Serve as a subject matter expert during committee discussions and executive escalations

• Therapeutic Class Management

  • Lead therapeutic class strategy reviews to ensure clinical positions remain current with evolving standards of care

  • Evaluate clinical evidence, treatment guidelines, real‑world data, and safety considerations

  • Identify opportunities for clinical optimization, standardization, and alignment across lines of business

  • Recommend updates to clinical positioning based on new evidence or utilization trends

• Utilization Management & Clinical Policy Development
  
  • Oversee custom policy writing for pharmacy and medical benefit drugs
  • Lead development and maintenance of UM clinical criteria, including prior authorization, step therapy, quantity limits, and coverage limitations
  • Conduct policy gap analyses to identify misalignment, outdated criteria, or regulatory risk
  • Ensure timely and clinically appropriate criteria updates, including:
    • NF (Non Formulary) drug criteria
    • Newly approved therapies
    • Safety driven or guideline driven changes
  • Ensure policies and criteria are defensible, auditable, and aligned with regulatory and accreditation standards

• Oversight, Escalation & Stakeholder Management
  • Manage stakeholder relationships with internal and external partners
  • Communicate clinical strategy clearly to both clinical and non clinical audiences
    

• Team Development & Resource Coordination
  • Provide direction, mentorship, and clinical oversight for pharmacists and analysts supporting governance, policy, and P&T work
  • Coordinate workload, prioritization, and resource allocation to ensure timely delivery of clinical deliverables
  • Support knowledge development, standard work, and process improvement within the clinical governance function
    

Required Qualifications

• Bachelor's degree in Pharmacy or PharmD required
• 5+ years of related work experience in health plan pharmacy, PBM clinical management, or related clinical leadership role beyond degree
• 1+ years of leadership experience

Required Certifications/Licensure

• Active Pharmacist license required

Preferred Qualifications

• Demonstrated experience with:
  • Clinical policy and UM criteria development
  • P&T Committee support and presentations
  • Drug evaluations and therapeutic class reviews
• Experience working within regulated environments (Medicare and/or Medicaid)
• Board certification (e.g., BCPS or other relevant specialty)
• Experience in plan-led or hybrid PBM models
• Familiarity with accreditation and regulatory frameworks (e.g., CMS, NCQA)
• Leadership experience overseeing clinical pharmacists or matrixed teams
• Clinical credibility and sound judgment
• Strong governance mindset and attention to consistency
• Ability to translate evidence into practical, defensible clinical positions
• Executive level presentation and communication skills
• Collaborative, cross functional leadership
  

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, St. Louis, MO, or Omaha, NE.

The full salary grade for this position is $113,400 - $194,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $113,400 - $170,100. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.  In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.