[Remote] PBM Eligibility, Accumulator, & Claims Team Lead (Operations)

Note: The job is a remote job and is open to candidates in USA. EmpiRx Health is the leading clinically-driven pharmacy benefits management company, focused on value-based pharmacy care. They are seeking an Operations Team Lead to manage a team of analysts, ensuring optimal performance in data, claims, eligibility, and accumulations while driving operational excellence and implementing client-specific solutions.

Responsibilities

• Lead POD team to resolve issues and close tickets effectively; ensure peak performance in data, claims, eligibility, and accumulations.
• Serve as subject matter expert on Eligibility, Accumulator Platforms, Plan Benefit Designs, and Claims Adjudication; collaborate with Data Engineering and IT on solutions.
• Build and maintain TPA relationships; ensure smooth onboarding for new clients and implementation of plan amendments.
• Drive configuration requirements for new client implementations; oversee user acceptance testing (UAT) and apply feedback for solution improvements.
• Monitor and drive performance metrics across operational areas; proactively identify and implement process enhancements.
• Manage feature backlogs, run scrum sessions, groom stories, and deliver solutions in an Agile environment.
• Ensure adherence to HIPAA, GDPR, PHI, PII, and internal data security standards.
• Partner with Client Management, Production Support, and other teams to maintain effective communication channels.

Skills

• 7+ in a related field; 5+ years in Eligibility, Accumulators, Claims Adjudication, and/or Data Analysis; 2+ years SQL proficiency (required).
• Experience with GDPR, HIPAA, PHI, PII compliance; Proficiency with SQL, GIT, DevOps; Analytical problem-solving skills.
• Strong time management and communication skills.
• Agile methodology experience.
• 2+ years Azure Databricks or ADF (preferred).

Education Requirements

• Bachelor’s degree in Computer Science, Information Technology, Business, or related discipline.

Company Overview

• EmpiRx Health is a Pharmacy Care Management organization that provides innovative pharmacy benefit and patient care management solutions. It was founded in 2014, and is headquartered in Montvale, New Jersey, USA, with a workforce of 201-500 employees. Its website is http://www.empirxhealth.com/.