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

• 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

Additional 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

Preferred Qualifications

• 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

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures

Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job

Potential pay for this position ranges from $164,000.00 - $279,000.00 based on experience and skills.

Prime Therapeutics (Santa Fe, NM)

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., At Prime Therapeutics (Prime), we are a different kind of PBM. We’re reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference.

We know that people make all the difference. If you’re ready for a purpose-driven career and are passionate about simplifying health care, let’s build the future of pharmacy together.