Claims Manager

Remote

Full Time

Experienced

PrudentRx seeks an analytical thinker who possess strong leadership skills and a passion for robust process to drive strong outcomes as a Claims Manager. As a Claims Manager you will provide oversight in all aspects of the claims department including tactful guidance of the Claims Specialist by motivating, coaching, and improving their work performance. Additional responsibilities will be to inform, evaluate and aid in enhancement of claims processes, implement business strategies assigned by the Leadership team and will direct vendors and internal business partners.

Position Details

United States- Remote/Telecommute
8:00 am-5:00 pm Est.
Equipment and hardware provided. Interviewing, orientation, and training are conducted virtually.

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

Requirements and Qualifications
Required

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.

Preferred

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.

Work From Home Requirement
(25/25mp) to execute all job functions. Additionally, the employee must provide a private
workspace with a desk and chair, free from distraction.

Physical Demands and Working Conditions
Duties are performed primarily in a home office setting utilizing Company provided computer equipment. While performing the duties of this job, you will regularly sit and talk. The employee is frequently required to use their hands. Employee will occasionally be required to stand and walk.
Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Benefits

Eligible for benefits within 30 days
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.

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Claims Manager

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