AVP Claims & Configuration - REMOTE

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

• 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

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.