AVP Claims & Configuration - REMOTE

Prime Therapeutics•Homer Township, IL

8d•$164,000 - $279,000•Remote

About The Position

The Associate Vice President, Claims & Configuration is responsible for the strategic leadership, operational performance, and continuous evolution of pharmacy benefit claims adjudication, benefit configuration capabilities, and network operations. This role ensures accurate, compliant, and scalable administration of pharmacy benefit programs while driving technology modernization, operational efficiency, and client satisfaction.

Requirements

Bachelor’s degree in Business, Health Care Administration, or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma from an accredited school or equivalent GED 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/people management experience
Must be eligible to work in the United States without the need for work visa or residency sponsorship
Demonstrated ability to distill complex concepts or situations into concise and compelling communications
Advanced problem-solving skills, including the ability to assess operational, financial, compliance, and client impacts of business decisions
Executive presence with 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 practices within highly regulated environments
Ability to lead and develop high-performing teams through coaching, succession planning, organizational design, and talent development

Nice To Haves

PBM experience, including claims adjudication, benefit configuration, formulary management, pricing, accumulators, and clinical program administration
Experience with pharmacy claims adjudication platforms, benefit configuration systems, and 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 that enhance operational efficiency, scalability, accuracy, data-driven decision making and customer experience
Own execution of the strategy, roadmap, and governance for pharmacy claims adjudication and benefit configuration capabilities, ensuring alignment with business, client, and regulatory requirements
Oversee the accurate interpretation and implementation of client benefit plans, formularies, accumulators, pricing, utilization management rules, and clinical programs within claims processing systems
Collaborate with key internal partners and business leaders to prioritize enhancements, drive operational transformation to support technology changes, and deliver strategic business outcomes
Establish and monitor key performance, quality, compliance, and financial metrics to ensure claims adjudication accuracy, configuration integrity, service excellence, and regulatory compliance
Lead operational 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 focused on operational excellence
Other duties as assigned