AVP Claims & Configuration - REMOTE

PRIME Therapeutics; United States; Remote; USD 164,000 - 279,000; Full time

Job summary

Prime Therapeutics is seeking an Associate Vice President to lead Claims & Configuration. You will drive strategic leadership, operational performance, and modernization across claims adjudication and configuration, ensuring compliant, scalable administration of pharmacy benefit programs.

You will oversee interpretation of client benefit plans, collaborate with senior leaders, and establish KPIs to measure quality, risk, and financial outcomes while guiding high-performing teams through

Qualifications

• Bachelor’s degree in Business, Health Care Administration, or related field or equivalent experience.
• 12 years of work experience in PBM, health plan, or healthcare operations.
• 8 years of leadership/people management experience.
• Eligible to work in the United States without visa or sponsorship.

Responsibilities

• Lead cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support.
• Drive modernization and continuous improvement to enhance efficiency, accuracy, and customer experience.
• Own strategy, roadmap, and governance for claims adjudication and configuration capabilities.
• Oversee interpretation and implementation of client benefit plans and pricing within claims processing systems.
• Collaborate with partners to prioritize enhancements and drive operational transformation.

Skills

Leadership

Communication

Education

Bachelor’s degree in Business/Healthcare Administration

Tools

PBM platforms

Claims processing systems

Job description

Job Posting Title AVP Claims & Configuration - REMOTE

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.

At Prime Therapeutics (Prime), we are a different kind of PBM. We’re reimagining pharmacy solutions to provide the care we would want for our loved ones.

Job Description

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.

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

Minimum Qualifications

• 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

Additional Qualifications

• 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

Preferred Qualifications

• 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

Security & Responsibilities

• Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures
• Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship.
• In addition, Prime retains the right to change or assign other duties to this job.

Potential Pay

Potential pay for this position ranges from $164,000.00 - $279,000.00 based on experience and skills.

Equal Opportunity & Diversity

Prime Therapeutics LLCis proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.