Remote AVP: Claims & Configuration Leader

Prime Therapeutics; Minneapolis (MN); On-site; USD 164,000 - 279,000; Full time

Job summary

Prime Therapeutics is seeking an AVP to lead Claims & Configuration, driving strategic direction, governance, and modernization across claims adjudication and benefit configuration. This remote role partners with clients and internal leadership to deliver scalable, compliant programs that improve accuracy and customer experience.

The ideal candidate has 12+ years in PBM or healthcare operations, 8+ years of leadership, and a proven ability to translate complex plans into clear roadmaps while

Qualifications

• Bachelor’s degree in Business, Health Care Administration, or related field; HS diploma from an accredited school or equivalent GED accepted with experience.
• 12+ years of work experience in PBM, health plan, or healthcare operations, including large-scale transformations.
• 8+ years of leadership/people management experience.
• Must be eligible to work in the United States without visa sponsorship.

Responsibilities

• Lead cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support.
• Drive modernization and continuous improvement initiatives to enhance efficiency, scalability, accuracy, data-driven decisions and customer experience.
• Own execution of the strategy, roadmap, and governance for pharmacy claims adjudication and benefit configuration capabilities.
• Oversee interpretation and implementation of client benefit plans, formularies, accumulators, pricing, utilization management rules, and clinical programs.
• Collaborate with internal partners and business leaders to prioritize enhancements and deliver strategic outcomes.
• Establish and monitor KPIs to ensure claims adjudication accuracy, configuration integrity, service excellence, and regulatory compliance.
• Lead initiatives to simplify processes, reduce risk, and address technical debt.
• Develop organizational capability through talent management and leadership of high-performing teams.
• Other duties as assigned

Skills

Executive leadership

Stakeholder management

Strategic communications

Education

Bachelor's degree in Business/Healthcare Administration or related field

HS diploma with equivalent experience

12+ years PBM/healthcare operations experience

Job description

Prime Therapeutics is seeking an AVP to lead Claims & Configuration, driving strategic direction, governance, and modernization across claims adjudication and benefit configuration. This remote role partners with clients and internal leadership to deliver scalable, compliant programs that improve accuracy and customer experience.

The ideal candidate has 12+ years in PBM or healthcare operations, 8+ years of leadership, and a proven ability to translate complex plans into clear roadmaps while