AVP Claims & Configuration - REMOTE
About The Position
The Associate Vice President, Claims & Configuration provides strategic leadership for pharmacy benefit claims adjudication, benefit configuration capabilities, and network operations. The role is accountable for operational performance and continuous evolution of these functions, ensuring accurate, compliant, and scalable administration of pharmacy benefit programs while advancing technology modernization, operational efficiency, and client satisfaction. The position leads cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support; owns the strategy, roadmap, and governance for claims and configuration capabilities; and oversees implementation of client benefit plans and related pharmacy program elements in claims processing systems. It partners with business leaders and internal teams to deliver strategic outcomes, monitors performance and compliance, leads process improvement and risk-reduction efforts, and develops organizational capability through talent management, succession planning, budget oversight, and team leadership. The role is remote.
Requirements
- Bachelor’s degree in Business, Health Care Administration, or a related area, or an equivalent combination of education and/or relevant work experience; a high school diploma from an accredited school or equivalent GED is required.
- 12 years of work experience in PBM, health plan, or healthcare operations, including experience with large-scale platform-enabled transformations.
- 8 years of leadership or people-management experience.
- Must be eligible to work in the United States without work visa or residency sponsorship.
- Ability to distill complex concepts or situations into concise, compelling communications.
- Advanced problem-solving skills, including assessing operational, financial, compliance, and client impacts of business decisions.
- Executive presence and exceptional communication, influencing, and stakeholder-management skills across operations, technology, clinical, product, and client-facing teams.
- Strong understanding of regulatory and industry requirements impacting 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.
- Ability to understand, comply with, and attest to job-specific security responsibilities and controls, and comply with applicable legal, regulatory, contractual, and internal requirements.
- Ability to perform the essential functions of the job, with reasonable accommodations provided when requested unless doing so would cause undue hardship.
Nice To Haves
- PBM experience, including claims adjudication, benefit configuration, formulary management, pricing, accumulators, and clinical program administration.
- Experience with pharmacy claims adjudication platforms and benefit configuration systems, including implementation of complex client benefit plans.
Responsibilities
- Lead cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support.
- Drive 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, aligning them with business, client, and regulatory requirements.
- Oversee accurate interpretation and implementation of client benefit plans, formularies, accumulators, pricing, utilization management rules, and clinical programs within claims processing systems.
- Collaborate with internal partners and business leaders to prioritize enhancements, support technology changes, and deliver strategic business outcomes.
- Establish and monitor key performance, quality, compliance, and financial metrics for claims accuracy, configuration integrity, service excellence, and regulatory compliance.
- Lead initiatives to simplify processes, reduce operational risk, improve speed-to-market, and address technical debt across claims and configuration ecosystems.
- Develop organizational capability through talent management, succession planning, budget oversight, and leadership of high-performing teams.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Executive
