Claims Manager

Summary

Join PrudentRx as a Claims Manager and leverage your analytical thinking and leadership skills to drive strong outcomes in our claims department. You will oversee all aspects of claims processing, mentor a team of specialists, and enhance claims processes. This remote position requires 3+ years of pharmacy claims experience and 2-3 years of direct management experience. You will be responsible for monitoring performance, identifying risks, and preparing reports for senior management. PrudentRx offers a comprehensive benefits package including health, dental, vision, paid parental leave, and a 401k with company match.

Requirements

• 3+ years of experience in pharmacy claims, healthcare claims management, or a similar role
• 2 - 3 years of direct management with a team
• Experience with commercial insurance plans

Responsibilities

• Oversee and manage the entire pharmacy claims review process to ensure accuracy, efficiency, and compliance
• Monitor and resolve discrepancies, including but not limited to coding, eligibility, and pharmacy errors
• Lead, mentor, and develop a team of claims specialists
• Set performance targets and monitor team metrics to ensure operational excellence
• Provide training and guidance on pharmacy claims review procedures, systems, and policies
• Identify risks in claims operations and implement strategies to mitigate them
• Manage the review and investigation of complex claims, including coding and pharmacy processing errors
• Coordinate with pharmacy teams to resolve claims issues
• Identify patterns in rejected claims and work to implement preventive measures
• Analyze pharmacy claims data to identify trends, inconsistencies, etc
• Prepare regular reports on claim performance, processing times, and reimbursement accuracy for senior management
• Use insights to optimize claims operations and recommend process improvements
• Complete all necessary continued learning and training requirements per department and company need
• Other essential duties as assigned

Preferred Qualifications

• Bachelor’s degree in healthcare administration, pharmacy, business, or a related field (or equivalent experience)
• Strong understanding of pharmacy benefit management (PBM) processes, formularies, and claim adjudication systems
• Experience with Medicare, Medicaid, and commercial insurance plans
• Knowledge of healthcare regulations, including but not limited to HIPAA, PHI, and industry best practices

Benefits

• Health (family)
• Dental
• Vision
• 100% Paid Parental Leave
• STD, LTD, Critical Illness and Accident
• Company Paid Life Insurance
• Company Paid Holidays (6)
• PTO cashout and rollover options
• Tuition Reimbursement
• 401(k) 100% company match up to 4% 90 days