[Remote] Manager, Claims Operations at SmithRx

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

5+ years in a leadership role with direct reports, preferably leading people in a remote or hybrid setting
8+ years of working knowledge of claims processing, medical billing, healthcare benefits, and/or pharmacy benefits in a PBM or payer environment
Experience with document management practices and member communication outreach is preferred
Executive-level communication and interpersonal skills
Must be based in one of the following states: Arkansas, Arizona, California, Colorado, Florida, Georgia, Kansas, Minnesota, Missouri, Nevada, North Carolina, South Carolina, Ohio, Pennsylvania, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin

Responsibilities

Establish clear team goals and priorities in alignment with the broader Plan Operations and Customer Success strategy
Manage the achievement of team and department objectives and key results (OKRs)
Perform regular team member coaching and identify team training opportunities, especially in new PBM technologies and compliance updates
Actively participate in the full interview and onboarding life cycle for new hires, focusing on skills relevant to automated claims systems
Identify process gaps and lead process improvement efforts for the claims operations team, emphasizing automation and digital transformation
Ensure claims approvals and/or denials are made in accordance with company practices, procedures, and regulatory requirements (e.g., CMS, state mandates)
Be accountable for ensuring timely completion of non-electronic pharmacy claims for direct member reimbursement
Oversee claim file review and analysis to support resolution of member disruption and complex claims issues
Support new group implementation activities related to claims system configuration and management
Oversee timely and accurate execution of mailed member communications associated with new group transitions to SmithRx

Skills

SmithRx

Pharmacy benefit management with transparent pricing

About SmithRx

SmithRx operates as a Pharmacy Benefit Manager (PBM) that focuses on managing prescription drug plans for self-insured employers and plan sponsors. The company uses a transparent pricing model called "Pass Through Pricing," where it charges only an administrative fee and passes all rebates from prescriptions directly to clients and their members. This model contrasts with traditional PBMs that often inflate drug prices and retain rebates for profit. SmithRx's clients benefit from a technology platform that utilizes real-time data to improve service delivery, ensuring efficient and high-quality pharmacy benefit management. The company also provides a concierge service to enhance support for both members and clients. SmithRx aims to simplify pharmacy benefits while maximizing value for its clients through transparency, advanced technology, and exceptional customer service.

San Francisco, CaliforniaHeadquarters

2016Year Founded

$94.8MTotal Funding

SERIES_CCompany Stage

HealthcareIndustries

201-500Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Health Savings Account/Flexible Spending Account

Unlimited Paid Time Off

Paid Holidays

Wellness Program

Commuter Benefits

Parental Leave

Mental Health Support

Professional Development Budget

Risks

Increased competition from technology-driven PBMs like Capital Rx could erode market share.

Rapid technological advancements may require costly updates to SmithRx's platform.

Potential regulatory scrutiny on PBM pricing models could impact SmithRx's business model.

Differentiation

SmithRx uses a transparent 'Pass Through Pricing' model, unlike traditional PBMs.

The company leverages real-time data for efficient pharmacy benefit management services.

SmithRx offers concierge-level service, enhancing customer satisfaction and support.

Upsides

SmithRx secured $60M in Series C funding, indicating strong investor confidence.

Partnership with Banjo Health enhances prior authorization processes using AI technology.

Collaboration with TheracosBio offers cost-effective drug options for Type 2 Diabetes.

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