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Clinical Program Director

Clinical Program Director

Specialty Search GroupDallas, TX, US
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Job Description

A growing healthcare technology organization is seeking a Clinical Program Director of Formulary to oversee the accurate and timely implementation of formulary data across medical benefit drugs, DMEPOS, immunizations, vaccinations, and test-and-treat services. This role ensures fee schedules and coding data are complete, compliant, and optimized for claims processing.

Key Responsibilities

  • Lead the review, update, and maintenance of formulary files and fee schedules.
  • Ensure compliance with federal / state payer rules and policies.
  • Act as subject matter expert in coding (HCPCS, CPT, NDC, ICD-10).
  • Oversee quality checks, pricing validations, and data accuracy.
  • Collaborate with internal teams and external partners to align systems and workflows.
  • Monitor regulatory updates and recommend system or process changes.

Qualifications

  • 7–10 years of healthcare experience, with 5+ years in formulary or benefit management.
  • Strong knowledge of claims adjudication, reimbursement operations, and coding standards.
  • Advanced Excel skills (pivot tables, lookups, reconciliations).
  • Coding certifications (CPC, CCS, CMRS) preferred.
  • Detail-oriented with strong analytical and communication skills.
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