Remote AVP, Pharmacy Claims & Configuration

Prime Therapeutics; Madison (WI); Remote; USD 164,000 - 279,000; Full time

Benefits offered by this job

Benefits package

Remote work

Bonus opportunities

Job summary

Prime Therapeutics is seeking an Associate Vice President, Claims & Configuration to lead strategic, operational, and modernization efforts for pharmacy benefit claims adjudication and configuration capabilities. The role focuses on delivering scalable, compliant processes that drive client satisfaction and efficient operations.

You will oversee governance, roadmap, and performance metrics while guiding teams across claims, configuration, testing, and production support to achieve business

Qualifications

• Bachelor’s degree in Business, Health Care Administration, or related field; 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

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

Skills

Strategic leadership

Cross-functional leadership

Stakeholder management

Data-driven decisions

Operational excellence

Regulatory compliance

Communication

Talent development

Education

Bachelor's degree in Business/Health Care Administration or related

Tools

PBM platforms

Benefit configuration systems

Job description

Prime Therapeutics is seeking an Associate Vice President, Claims & Configuration to lead strategic, operational, and modernization efforts for pharmacy benefit claims adjudication and configuration capabilities. The role focuses on delivering scalable, compliant processes that drive client satisfaction and efficient operations.

You will oversee governance, roadmap, and performance metrics while guiding teams across claims, configuration, testing, and production support to achieve business