AVP Claims – Configuration

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🔥 1 minute ago

🇺🇸 United States – Remote

💵 $164k - $279k / year

⏰ Full Time

🔴 Lead

👔 Vice President

🦅 H1B Visa Sponsor

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Prime Therapeutics

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1998

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Prime Therapeutics is a trusted pharmacy solutions provider dedicated to transforming health care through innovation and transparency. The company offers a wide range of services including clinical solutions for improved member outcomes, drug access and affordability, specialty drug management, and condition management for chronic health issues. With over 7,000 employees, Prime Therapeutics aims to challenge norms in the pharmacy industry, providing exceptional experiences and simplifying the complex for millions across the nation. Their mission goes beyond profit, focusing on creating transformative impacts with long-term solutions, utilizing modern technology and holistic approaches in specialty pharmacy management. Owned by mission-driven partners, Prime Therapeutics emphasizes true transparency and conflict-free service, fostering a culture of care and shared purpose in health care.

📋 Description

• Lead cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support • Lead modernization and continuous improvement initiatives to improve operational efficiency, scalability, accuracy, data-driven decision making, and customer experience • Own the strategy, roadmap, and governance for pharmacy claims adjudication and benefit configuration capabilities • Oversee interpretation and implementation of client benefit plans, formularies, accumulators, pricing, utilization management rules, and clinical programs in claims processing systems • Collaborate with internal partners and business leaders to prioritize enhancements, drive operational transformation, and deliver strategic business outcomes • Establish and monitor performance, quality, compliance, and financial metrics • Lead initiatives to simplify processes, reduce operational risk, improve speed-to-market, and address technical debt • Develop organizational capability through talent management, succession planning, budget oversight, and leadership of high-performing teams • Comply with job-specific security responsibilities, legal, regulatory, contractual, and internal policy requirements • Perform other duties as assigned

🎯 Requirements

• Bachelor's degree in Business, Health Care Administration, or related area of study, or equivalent combination of education and/or relevant work experience • High school diploma from an accredited school or equivalent GED required • 12 years of work experience in PBM, health plan, or healthcare operations, including large-scale platform-enabled transformations • 8 years of leadership/people management experience • Must be eligible to work in the United States without work visa or residency sponsorship • Ability to distill complex concepts into concise and compelling communications • Advanced problem-solving skills across operational, financial, compliance, and client impacts • Executive presence with exceptional communication, influencing, and stakeholder management skills • Strong understanding of regulatory and industry requirements for pharmacy benefit administration and claims processing • Expertise in operational excellence, quality management, risk mitigation, and governance in highly regulated environments • Ability to lead and develop high-performing teams through coaching, succession planning, organizational design, and talent development • PBM experience, including claims adjudication, benefit configuration, formulary management, pricing, accumulators, and clinical program administration preferred • Experience with pharmacy claims adjudication platforms, benefit configuration systems, and complex client benefit plans preferred • Ability to perform essential job functions, with reasonable accommodations available when requested

🏖️ Benefits

• Potential pay range of $164,000.00–$279,000.00 based on experience and skills • Benefits, incentives, and additional compensation (details provided on the Benefits Page) • Equal opportunity and affirmative action employment • Reasonable accommodations for qualified applicants with disabilities • Tobacco-Free Workplace