Pharmacy Claims Lead

FreeMarketHealth•Pittsburgh, PA

7d•Hybrid

About The Position

Free Market Health is seeking a Claims Analyst Lead to review and ensure the accuracy, reliability, and efficiency of healthcare claims processing across medical and pharmacy claims. This role is ideal for someone who enjoys solving complex operational issues, partnering across teams, and improving processes that directly support timely, accurate payments and strong partner outcomes. This position will be the team's go to Claims subject matter expert and will report directly to the Director, Claims Support. In this role, you will serve as a key operational resource for escalated claims issues, clearinghouse support, payment reconciliation, and workflow improvement. You will collaborate closely with teams across Pharmacy Services, Client Services, Finance, Technology Services, Software Engineering, and external payer and pharmacy partners to resolve issues, identify root causes, and support scalable claims operations.

Requirements

A minimum of 4 years of experience in pharmacy, healthcare, operations, or a related environment, with hands-on involvement in healthcare claims or related transactions.
Strong understanding of medical and pharmacy claims workflows and operational processes.
Familiarity with industry standards and formats such as NCPDP, X12, or similar healthcare data standards.
Proficiency with Microsoft Office applications and working knowledge of SQL.
Strong communication, organization, problem-solving, and attention to detail.
Ability to work cross-functionally, evaluate complex issues, and drive practical operational solutions.

Nice To Haves

Experience with FHIR, XML, JSON, or other healthcare data formats.
College degree preferred.

Responsibilities

Lead resolution of escalated claim payment issues across medical and pharmacy claims, ensuring timely, accurate outcomes.
Oversee medical claims clearinghouse operations and support consistent, high-quality claims processing.
Partner with Technology Services and Software Engineering to diagnose and resolve technical issues impacting claims processing and system performance.
Collaborate cross-functionally with Referral Support, Intake Support, Pharmacy Services, Client Services, and Finance to improve workflows, enhance automation, and support payment accuracy.
Identify and resolve systemic payment issues related to payer or PBM configuration, addressing root causes and preventing recurrence.
Coordinate with payer clients on claim reconciliation and payment issue resolution to support financial accuracy and partner satisfaction.
Support payer and pharmacy partners with claim submission processes, onboarding, and ongoing operational needs.
Develop and manage structured processes, such as rebill cycles, to correct claims paid at incorrect rates and improve operational consistency.