[Hiring] Sr. Manager, Claims Operations @Navitus Health Solutions

Role Description

Archimedes is seeking a Sr. Manager, Claims Operations to join our team! The Sr. Manager, Claims Operations is responsible for leading and optimizing end-to-end operational functions, ensuring accurate, timely, and compliant execution of pharmacy benefit services within the claim operations team. This role oversees complex operational workflows, external pharmacy and vendor performance, and cross-functional coordination to support client commitments, regulatory requirements, and financial integrity.

The Sr. Manager, Claims Operations acts as both a strategic operator and a hands-on leader, driving process improvement, issue resolution, and operational readiness across direct team and cross-functional teams. Areas of responsibility include:

• Claims configuration and processing
• Claims quality
• Fee schedule management
• Direct pharmacy relationship management
• Copay assistance program oversight
• Other critical duties as assigned by leadership

Responsibilities

• Provide leadership and oversight over the claim operations team to ensure efficient, accurate, and compliant execution of business operations.
• Manage day-to-day operational performance, ensuring service levels, quality standards, and business objectives are met, including any claim operations related performance guarantees.
• Lead, coach, and develop the team members, including performance management, goal setting, and professional development.
• Ensure operational readiness for new initiatives, implementations, regulatory changes, and ongoing business needs.
• Identify, assess, and mitigate operational risks, and implement corrective actions as necessary.
• Drive continuous process improvement initiatives to enhance efficiency, accuracy, scalability, and quality across all claim operations core functions.
• Establish, maintain, and enforce operational policies, procedures, and controls.
• Oversee daily claims QA and related QA processes for configuration, fee schedules and all other quality assurance activities, ensuring appropriate monitoring and reporting mechanisms are in place.
• Collaborate with internal stakeholders and external vendors, including partner pharmacies, to support operational objectives and resolve issues.
• Monitor pharmacy and adjudicator performance against contractual requirements and service level agreements.
• Serve as an escalation point for complex or high impact operational issues and drive timely resolution.
• Ensure compliance with applicable laws, regulations, and internal governance standards.
• Support audits, reviews, and remediation activities as required.
• Provide regular operational reporting, insights, and recommendations to senior leadership.
• Communicate operational status, risks, and outcomes clearly to cross-functional partners.
• Establish, mentor, and develop team members through coaching, feedback, and career planning, ensuring a pipeline of future leaders and a culture of accountability and growth.
• Participate in, adhere to, and support compliance, people and culture, and learning programs.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree in Business Administration or related field, or equivalent work experience, required.
• 5+ years of claims operations experience required.
• 3+ years of progressive leadership experience, which may include leading individual contributors or teams, or equivalent leadership experience such as coaching, mentoring, or leading complex initiatives or projects, required.
• Experience with specialty claims, configuration and complex programs such as copay assistance strongly preferred.
• Experience in healthcare required.

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance.
• 20 days paid time off.
• 4 weeks paid parental leave.
• 9 paid holidays.
• 401K company match of up to 5% - No vesting requirement.
• Adoption Assistance Program.
• Flexible Spending Account.
• Educational Assistance Plan and Professional Membership assistance.
• Referral Bonus Program – up to $750!