Job Title: Pharmacy Claims Lead Location: Remote/Current Location USA What You Will Get To Do: Pharmacy Claims Lead

• Pharmacy Claims Lead provides strategic and operational leadership for pharmacy claims adjudication, configuration, and oversight within a rules-based claims environment, with a focus on automated validation, monitoring, and issue resolution processes aligned to current NCPDP standards.

• This role owns the integrity and performance of pharmacy claims functionality across Commercial, Medicare, and Medicaid lines of business, with direct accountability to operational metrics, quality measures, and contractual performance guarantees.

• The Pharmacy Claims Lead leads a team responsible for configuring, testing, validating, and monitoring claims logic and related workflows, ensuring accuracy, compliance, and scalability. This role operates at the intersection of business requirements, system behavior, and data outcomes, and is critical to maintaining claims integrity in a technology-driven organization.

Key Responsibilities Leadership & Talent Development

• Lead, coach, and develop a team responsible for pharmacy claims configuration, validation, monitoring, and issue resolution.

• Shift team focus from manual execution to configuration, controls, and outcome-based monitoring.

• Establish performance expectations tied to claims accuracy, processing quality, system reliability, and service-level attainment.

• Build capability in data interpretation, root cause analysis, and operational control thinking.

• Prioritize work across competing demands, ensuring the team is focused on high-impact activities that protect performance guarantees.

• Develop talent for a technology-enabled environment, including analytical and systems-based thinking.

Operational Ownership & Controls

• Own pharmacy claims adjudication logic and operational behavior, including Transition and Long Term Care (LTC). 

• Ensure claims configuration and system rules are properly implemented, tested, and continuously validated against business and regulatory requirements.

• Monitor claims performance and system outputs to identify defects, anomalies, and downstream impacts.

• Drive resolution of complex issues through root cause analysis, not just issue remediation.

• Move the function toward proactive monitoring and exception management, reducing reliance on manual review and reactive fixes.

• Partner with technology teams to strengthen validation, monitoring, and issue resolution capabilities, improving the reliability and effectiveness of automated claims processing.

Analytics, Compliance & Performance Management

• Develop and maintain operational dashboards and metrics that track claims performance, financial accuracy, and compliance adherence.

• Use data to detect trends, identify risks, and drive corrective action.

• Ensure adherence to federal, state, and contractual requirements, including performance guarantees tied to claims outcomes.

• Support audit readiness through effective documentation, traceability of logic, and validation of system behavior.

• Evolve reporting from static metrics to actionable insights that drive operational decisions.

Strategy, Systems & Transformation

• Serve as the functional authority for pharmacy claims logic and adjudication behavior.

• Partner with business, compliance, clinical, and technology teams to translate requirements into system configuration and measurable outcomes.

• Evaluate system capabilities and emerging technologies to improve scalability, accuracy, and automation.

• Lead initiatives that modernize claims operations, including reduction of manual work, improved configuration governance, and enhanced monitoring.

• Influence how pharmacy claims operations evolve from legacy workflows to technology-enabled, data-driven processes.

What you will bring:

• Demonstrated leadership experience in a complex operational or systems environment, including direct people management or equivalent leadership responsibility.

• Experience leading teams responsible for configuration, validation, monitoring, or operational control functions.

• Strong analytical capability, including ability to interpret data, identify patterns, and drive action.

• Experience with operational metrics, reporting, and performance measurement.

• Proficiency with Excel and SQL; ability to work with structured data and translate it into insights.

• Strong stakeholder management across technical and business domains.

• Ability to lead through ambiguity, change, and evolving operating models.

• Strong problem-solving skills with emphasis on root cause analysis and prevention, not just resolution.

Preferred Qualifications

• Bachelor’s degree or equivalent experience in healthcare, pharmacy operations, or related field.

• Experience in pharmacy claims, PBM operations, or adjudication systems.

• Experience in highly regulated environments with accountability for compliance and audit outcomes.

• Exposure to automation, workflow optimization, or system modernization initiatives.

• Experience working with claims monitoring, exception management, or controls frameworks.

• Project leadership experience in cross-functional environments.

Leadership Expectations

• Builds a culture of accountability, precision, and continuous improvement.

• Develops teams to operate in a controls-oriented, data-driven environment.

• Demonstrates sound judgment balancing operational execution, system behavior, and contractual obligations.

• Drives execution with focus on outcomes, not just activity.

• Partners across the enterprise to ensure claims operations are aligned with technology and business strategy.

• Embraces change and actively supports the transition to a modern, automated claims environment.

SS&C Technologies offers a comprehensive total rewards package designed to support your wellbeing, growth, and future. Our benefits include medical, dental, and vision coverage; a 401(k) plan with company match; paid time off, holidays, and parental leave; and professional development reimbursement opportunity.

 

 

Actual base salary will vary based on several factors, including but not limited to relevant skills, prior experience, education, demonstrated performance, and geographic location.

Illinois: The expected base salary for the position is between 120000 USD to 130000 USD.

 

 

In addition, employees in this role may be eligible for consideration on an annual basis for a discretionary bonus and/or equity awards, such as restricted stock units or stock options, based upon individual and business performance at the company’s discretion. 

 

 

 

Applications will be accepted on an ongoing basis until the position is filled.