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.
Job Posting TitleAVP Claims & Configuration - REMOTEJob DescriptionThe 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
Minimum 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
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
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Skills Required
- Bachelor's degree in Business, Health Care Administration, or related field or equivalent combination of education and experience
- 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
- Eligible to work in the United States without the need for work visa or residency sponsorship
- Ability to distill complex concepts into concise, compelling communications
- Advanced problem-solving skills including assessment of operational, financial, compliance, and client impacts
- Executive presence with strong communication, influencing, and stakeholder management skills
- 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, succession planning, and organizational design
- 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
Prime Therapeutics Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Prime Therapeutics and has not been reviewed or approved by Prime Therapeutics.
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Healthcare Strength — Health coverage is described as comprehensive, with medical, dental, and vision options and plan designs that include low deductibles for some choices. Wellness screenings and related incentives add perceived value to the health offering.
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Retirement Support — Retirement benefits stand out through a 401(k) match that is characterized as generous and immediately vested. This structure improves the overall long-term value of the total rewards package.
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Strong & Reliable Incentives — Annual incentive bonuses are positioned as a meaningful component of total compensation and are often portrayed as substantial when performance goals are met. Incentive eligibility appears broadly available across roles, boosting the perceived completeness of rewards.
Prime Therapeutics Insights
What We Do
Everything we do is connected to helping people get the medicine they need to feel better and live well. It’s meaningful work and we’ve been doing it for over 20 years. In the pharmacy benefit management (PBM)industry, we’re different. We’re owned by 18 not-for-profit Blue Cross and Blue Shield health plans. This allows us to control costs and empower our employees to put members first. It’s a successful combination. We have the lowest pharmacy trend in the industry and serve 28+ million members throughout the US. In addition to core PBM services, we work closely with our clients to implement the right benefit design, clinical and specialty programs, formulary and networks. A few key products: • NetResults™ • Specialty Drug Management • Best in Care™ • GuidedHealth® • Advanced Fraud, Waste and Abuse: Member and Prescriber Investigations • Prime Analytics™ • CareCentered Contracting™Controlled Substance Management Program Join us! Prime is always looking for smart, purposeful people to join our team. We’re growing fast which means there are plenty of opportunities to advance and grow in your career. At the same time, Prime supports flexibility and offers generous PTO so you can enjoy an enviable work/life balance. We’re a privately held company -big enough to make a difference and small enough for you to have an impact. Follow Prime on LinkedIn to learn more.
