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Manager, Claims Operations

Remote

Who We Are:

SmithRx is a rapidly growing, venture-backed Health-Tech company.  Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service.  With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.

We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:

  • Integrity: Our purpose guides our actions and gives us confidence in the path ahead. With unwavering honesty and dependability, we embrace the pressure of challenging the old and exemplify ethical leadership to create the new.
  • Courage: We face continuous challenges with grit and resilience. We embrace the discomfort of the unknown by balancing autonomy with empathy, and ownership with vulnerability. We boldly challenge the status quo to keep moving forward—always.
  • Together: The success of SmithRx reflects the strength of our partnerships and the commitment of our team. Our shared values bind us together and make us one. When one falls, we all fall; when one rises, we all rise.

Job Summary:
The Manager, Claims Operations will lead the company’s day-to-day operational activities that support behind the scenes functions related to claims processing, mass member communications, implementation activities, and other technical responsibilities. This position will report to SmithRx’s Director, Plan Operations

In order to be eligible for this position applicants 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.

What you will do:

  • This role requires a balance of leadership, operational execution, and a forward-thinking approach to PBM technology and data.

    Leadership & Strategy

    • 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.

    Claims Operations & Process Excellence

    • 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.

What you will bring to SmithRx:

  • 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, with the ability to effectively navigate and mediate conflict and foster honest dialogue.
  • Passion for developing, inspiring, and leading teams composed of less-experienced emplo`yees.
  • Execution-focused ethos - you are a solutions-oriented problem solver and efficiency-driven. 
  • Organized and thoughtful with the ability to handle competing issues and prioritize accordingly. 
  • Comfortable with leading teams in a fast-changing environment.

What SmithRx Offers You: 

  • Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life Insurance and AD&D Insurance
  • Flexible Spending Benefits 
  • 401(k) Retirement Savings Program 
  • Short-term and long-term disability
  • Discretionary Paid Time Off 
  • 12 Paid Holidays
  • Wellness Benefits
  • Commuter Benefits 
  • Paid Parental Leave benefits
  • Employee Assistance Program (EAP)
  • Well-stocked kitchen in office locations
  • Professional development and training opportunities

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