Claims Consultant

Acrisure Great Lakes Partners Insurance Services, LLC•Cherry Grove Township, MI

3d•Onsite

About The Position

The Claims Consultant supports the administration and processing of pharmacy benefit claims for self-funded employer health plans. The role serves as a liaison between clients, plan members, pharmacies, pharmacy benefit managers (PBMs), third-party administrators (TPAs), and internal teams to ensure claims are processed accurately, efficiently, and in accordance with plan provisions and regulatory requirements. The position analyzes claim issues, resolves discrepancies, identifies cost-saving opportunities, and provides service to clients and stakeholders. It contributes to ARORx's mission of helping self-funded organizations optimize pharmacy benefits, manage costs, and improve plan performance. Candidates should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

Requirements

Minimum of 3 years of experience in health insurance, pharmacy benefits, claims administration, healthcare operations, or a related industry.
Strong verbal and written communication skills.
Strong understanding of healthcare claims processing and pharmacy benefit administration.
Knowledge of prescription drug benefit structures, formularies, specialty pharmacy programs, and utilization management processes.
Excellent analytical and problem-solving skills, including investigating complex claim issues, identifying root causes, and determining appropriate resolutions.
Ability to assess urgency independently, prioritize responsibilities, research and resolve issues using available resources, determine next steps before escalation, and ensure timely follow-up, appropriate escalation, and clear communication.
Advanced attention to detail and commitment to accuracy.
Strong customer service and relationship management skills.
Ability to communicate professionally with members, pharmacies, providers, and internal teams.
Proficiency in Microsoft Office Suite, particularly Excel.
Strong learning agility and adaptability to learn new processes, systems, client requirements, and pharmacy benefit programs and adapt to procedural, operational, or organizational changes.
Strong organizational and documentation skills.
Comfort with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

Nice To Haves

Bachelor’s degree in business, Healthcare Administration, Finance, Insurance, Public Health, or a related field preferred.
Experience working with self-funded health plans, PBMs, TPAs, or pharmacy benefit programs preferred.
Equivalent combination of education and experience may be considered.
Bilingual English/Spanish, with the ability to communicate effectively with Spanish-speaking members, clients, pharmacies, and business partners.
Experience working with claims adjudication systems, reporting platforms, and healthcare data preferred.

Responsibilities

Review, investigate, and resolve pharmacy benefit claim issues and inquiries in a timely manner.
Analyze claim adjudication outcomes and identify discrepancies, processing errors, and opportunities for corrective action.
Coordinate with pharmacies, PBMs, TPAs, carriers, brokers, and plan sponsors to resolve complex claim concerns.
Research eligibility, benefit design, prior authorization requirements, and plan provisions to determine claim outcomes.
Monitor claim payment accuracy and compliance with contractual and regulatory requirements.
Assist in auditing and reconciling pharmacy claims data.
Support client implementation projects and benefit plan changes.
Maintain accurate documentation of claim investigations, resolutions, and communications.
Partner with Account Management, Clinical, and Operations teams to ensure seamless service delivery.
Provide education and guidance to members regarding claim processes, pharmacy benefits, and cost management strategies.
Stay current on pharmacy benefit trends, industry regulations, and healthcare legislation impacting claims administration.
Perform other duties as assigned.