Remote AVP Claims & Configuration Leader

Prime Therapeutics; Trenton (NJ); A distancia; USD 164.000 - 279.000; Jornada completa

Descripción de la vacante

Prime Therapeutics, a leading PBM, seeks an Associate Vice President of Claims & Configuration to lead strategic direction, governance, and performance for claims adjudication and configuration capabilities. This role directs modernization efforts and oversees client benefit plans, pricing, and regulatory compliance from a remote location in the United States.

The ideal candidate has extensive PBM leadership experience, deep regulatory knowledge, and a track record of delivering scalable,

Formación

• Bachelor's degree in Business, Health Care Administration, or related field; HS diploma or GED required.
• 12 years of work experience in PBM, health plan, or healthcare operations, including 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 with awareness of operational, financial, compliance, and client impacts.
• Executive presence with strong communication, influencing, and stakeholder management across diverse 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 in regulated environments.
• Ability to lead and develop high-performing teams through coaching and talent development.

Responsabilidades

• 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.

Conocimientos

Executive presence

Strategic leadership

Regulatory knowledge

Stakeholder management

Operational excellence

Talent development

Educación

Bachelor’s degree in Business/Health Care Administration

HS diploma or GED

Herramientas

PBM platforms

Benefit configuration systems

Claims adjudication platforms

Descripción del empleo

Prime Therapeutics, a leading PBM, seeks an Associate Vice President of Claims & Configuration to lead strategic direction, governance, and performance for claims adjudication and configuration capabilities. This role directs modernization efforts and oversees client benefit plans, pricing, and regulatory compliance from a remote location in the United States.

The ideal candidate has extensive PBM leadership experience, deep regulatory knowledge, and a track record of delivering scalable,