AVP Claims & Configuration - REMOTE
$164,000–$279,000 year
RemoteUnited States
Job Summary
Lead cross-functional teams responsible for claims adjudication, benefit configuration, testing, and production support while driving modernization and continuous improvement initiatives. 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. Establish and monitor key performance, quality, compliance, and financial metrics to ensure claims adjudication accuracy, configuration integrity, 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.
Required 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
Desired 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
- 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
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