Community Health Options jobs

With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse Apply industry, state, and federal regulations and guidelines Assess findings to detect patterns of fraud, waste, and abuse Make accurate claim decisions based on policies, payment rules, coding guidelines, and clinical judgment JOB SPECIFIC KEY COMPETENCIES (KSAs) Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Experienced as RN licensed in state of residence Bachelor s degree in business, healthcare administration, or other related functional area is required. Certified Clinical Documentation Specialist (CCDS) Certified Coding Specialist (CCS) Certified Fraud Examiner (CFE) preferred 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse 5+ years of experience working in health care hospital and physician practices and/or health insurance environment 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity A dedicated workspace with high-speed internet (=50 Mbps down / =10 Mbps up) and wired connectivity is required.

Why AAA Life AAA Life is a respected and trusted American brand that has been focusing on Life Insurance and Annuity Products since 1969. At AAA Life we have over 1.8 million policies where we take pride in earning the trust of our policyholders who understand our promise to be there for them - and their families - when we're needed most. By joining the AAA Life team, you are joining a company that genuinely cares about helping each other, with a devotion to protect the lives of those around us. We embrace a diverse, equitable, inclusive culture where all associates can feel a sense of belonging and use their unique talents and perspective to influence, innovate, motivate, and thrive. AAA Life Insurance is hiring for licensed Life Insurance Sales Agents! The Life Sales Agent is responsible for the sale of AAA Life Insurance products in a high volume, fast paced call center environment. Explains product features and benefits to potential customers for the purpose of promoting and selling various insurance products in order to achieve specific production goals. Provides services factoring in all applicable rules (underwriting, business procedures, etc) and performs follow-up as necessary to ensure placement of written business. Responsibilities What You'll Do Promotes the sale of AAA Life Insurance products in a call-center environment. Recognizes and promotes cross-sell and up-sell opportunities in an effort to achieve specific sales production expectations. Completes appropriate applications and forms as necessary. Follows internal processing procedures to assure that transactions are handled in accordance with company policies and procedures. Provides advanced technical and product information in response to customers' inquiries to ensure achievement of established quality/sales goals with the end result to promote the sale of all AAA Life products. Achieve established sales goals and other performance expectations as defined by management. Successfully complete appropriate training relative to all AAA Life products and services. Perform other job duties as assigned or required. Qualifications What you offer High School degree or equivalent required; some college coursework preferred. Minimum 2 or more years of sales and/or customer service experience required; at least one year in the insurance and/or financial services preferred. Current license to sell life insurance Proven track record of providing a high level of customer-focused services. Strong knowledge of MS Office and web related products Ability to enter information on various screens using a PC Keyboard Managing and navigating multiple sources of information and applying as needed Work extended/irregular hours to include weekends/holidays Strong inter-personal skills Strong verbal and written communication skills, including the ability to explain complex issues to a range of audiences Ability to work in a team environment What We offer: A collaborative, energetic work environment where you can put your passion for people to work Medical, Dental, Vision, Life and Disability coverage available day one Pension Plan Performance-based incentive plan 401k available with a Company match Holidays and Paid Time Off AAA Basic Membership #LI-Remote While performing the duties of this job, the employee is frequently required to stand, walk, sit, use hands to finger, handle, or feel, talk, hear and concentrate. Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus. This job requires the ability to perform duties contained in the job description for this position, including, but not limited to, the above requirements. Reasonable accommodation will be made for otherwise qualified applicants as needed to enable them to fulfill these requirements. We are committed to ensuring equal employment opportunities for all job applicants and employees. Employment decisions are based upon job-related reasons regardless of an applicant's race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, marital status, genetic information, protected veteran status, or any other status protected by law.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Senior Trainer - REMOTE **Job Description** **The Senior Trainer oversees all aspects of training development and deployment. The Senior Trainer partners and consults with various business leaders including executives, subject matter experts, and vendors to develop and deliver high-quality training and developmental programs for internal and external customers.** **Responsibilities** **Deliver training using a variety of methods, including coaching, classroom facilitation, and 360 feedback** **Analyze, develop and update existing training programs and materials to enhance and reinforce performance development, and company or departmental needs with stakeholders** **Drive the development and delivery of impactful training programs by leading trainer teams, optimizing class setup, and leveraging performance insights to support organizational growth and excellence** **Provide leadership for training with stakeholders and projects, including needs assessment, design/development, project management, implementation, and/or vendor management** **Serve as escalation point for training-related issues and process improvements** **Maintain subject matter expertise in assigned area of training to support enterprise initiatives** **Other duties as assigned** **Minimum Qualifications** **Bachelor's degree in Business, Human Resources, Training, Education, Organizational Development or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required** **5 years of work experience in education, training, account/client management and/or project management** **Must be eligible to work in the United States without the need for work visa or residency sponsorship** **Additional Qualifications** **Advanced delivery skills including communication, presentation, coaching and facilitation** **Demonstrated knowledge of adult learning principles, practices, and procedures, and methodologies** **Excellent verbal and written communication, presentation, facilitation, and interpersonal skills** **Ability to manage multiple, complex projects simultaneously without compromising quality** **Proficient in the use of Microsoft Office Products including Excel, Word and PowerPoint** **Preferred Qualifications** **PBM/health care experience** **Experience working directly with Clients/Vendors** **Experience mentoring/training other Trainers** **Experience with e-learning and learning management system applications (ie. HTML, Captivate, Articulate)** **ATD Certification in Adult Learning or Instructional Design** **Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures** **Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job.** Potential pay for this position ranges from $74,000.00 - $118,000.00 based on experience and skills. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Principal Solution Strategist - JUDI - Remote **** **We are currently on the lookout for a Principal Solution Strategist to help lead the Medicare and Medicaid migrations for the JUDI program.** **Job Description** The Principal Solution Strategist is responsible for partnering with cross functional stakeholders and senior leaders to implement innovative solutions that advance or achieve Prime's strategic priorities. This role will drive operational readiness for new business and/or products, drive operating efficiencies and reduction of operating expenses, own the stakeholder experience, and is a key decision maker on building new capabilities. This role involves complex decision making, is client facing, and acts as a strategic liaison between the business and vendor partners to ensure the Strategic Solutions roadmap is created, managed, and executed timely within business and contractual requirements and in support of Prime's strategy. **Responsibilities** + Oversee one or more strategic initiatives in partnership with Operations and/or IT + Collaborate with all levels of cross-functional stakeholders and senior leaders to advance strategic enterprise initiatives; responsibilities may include conducting research, providing input on test strategy and test cases, leading the development of data analytics solutions that deliver actionable insights, driving end-to-end process improvement and other efficiencies to reduce operating expenses, supporting the implementation or uplift of capabilities, tools and platforms + Create strong vision alignment with internal and external business partners, vendors, business segments, and functional areas, ensuring coordination and unified approach to work; partner with key internal and external stakeholders to educate, implement, and provide strategic consultation + Proactively build and maintain a network of key relationships to continuously understand business dynamics and appropriately influence business decisions + Monitor ongoing product performance and usage of features and act as point of contact for enterprise, vendor, and client questions, concerns and suggestions + Serve as a thought leader to help drive teams to conclusions and realized business value in tangible product outcomes + Responsible for internal and external communication and messaging to improve and foster transparency, education, and cohesive enterprise messaging + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in business, Healthcare Administration, IT or related area of study, or equivalent combination of education and/or relevant work experience + 7 years of related work experience in product development, business analysis or leading business processes + Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Understanding the adjudication process + Strong verbal and written communication skills + Ability to present complex material to a variety of audiences in plain language + Ability to self-learn new processes and/or software to solve analytic problems + Demonstrated influencing skills with the ability to lead and drive change + Proven ability in building a trusting and safe environment to air issues and concerns and support collaborative or independent problem solving **Preferred Qualifications** + PBM/health experience + Medicare, Medicaid, CMS background + Desire to be a SME + Work with Prime solutions that support Echo, Encounter, Edge, FIR, NX or willing to learn + Experience working on and coaching cross-functional teams aligned to a strategic priority + Experience driving process optimization, improving efficiencies or reducing operating costs + Experience implementing new tools, platforms and products + Experience using queries, thorough understanding of pharmaceutical claims data and general understanding of medical claims data; highly analytical + Experience with commercial software design concepts, practices, and procedures Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $108,000.00 - $184,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting TitleIT Strategy & Planning Analyst, Principal - RemoteJob Description The IT Strategy & Planning Analyst - Principal plays a critical role in advancing Prime's technology planning and delivery operating model. This position is responsible for driving organizational alignment through training, coaching, and continuous improvement initiatives. The role serves as a subject matter expert, ensuring that processes, tools, and services are optimized to support Prime's operating model. By partnering with stakeholders across IT, Finance and business operations, this position fosters collaboration, enhances service delivery, and promotes a culture of operational excellence. Responsibilities Deliver training and provide coaching on Prime's technology planning and delivery operating model to all levels of the organization. Partner with stakeholders to gather improvement opportunities and lead the implementation of tool and process changes, ensuring high-quality delivery and effective communication. Maintain and update training materials, ensuring enhancements reflect evolving operating model changes. Manage the operating model SharePoint site and other collateral to ensure accurate documentation of roles, responsibilities, and team alignment. Provide oversight of the operating model deliverable templates and repository to ensure alignment with standards. Execute and coordinate complex, cross-functional processes, including data management, reporting, workflow processing, and communication of status updates. Other duties as assigned Minimum Qualifications Bachelor's degree in business, Computer Science or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED required 7 years of work experience in IT, business operations or related field including 3 years of experience in process design and improvement Must be eligible to work in the United States without need for work visa or residency sponsorship Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Ability to influence leaders without authority Strong coaching skills Strong facilitation skills Highly organized Ability to deliver training classes Solves complex problems by taking a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information Ability to translate abstract concepts and problems into comprehensive solutions Anticipates potential objections and influences others to adopt a different point of view Communicates complex concepts at all levels across the area or department Established presenter of material adapted to the respective audience Preferred Qualifications PBM or healthcare industry experience Project management and/or Scrum Master experience Experience in managing one or more services in the IT Strategy and Planning function Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

The Supervisor, Case Management (CM) supports the Senior Manager (Sr. M) and Assistant Manager, Medical Management (MM) in daily operations related to MM systems, integration, configuration, testing, functionality, quality, staff education, CM related reports and day-to-day staff operations. The Supervisor, CM is the primary contact for CM related escalations and represents CM in cross-functional internal collaborations.The Supervisor, CM adheres to Community Health Options MM approach that balances advocacy for the individual with stewardship for the entire membership through effective utilization management strategies. Incumbent remains nimble and consistently demonstrates ability to swiftly adapt and flex work assignments to meet daily operational priorities. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES The Supervisor, CM supports the Sr. M and Assistant Manager in ensuring CM documentation platform configuration, integration, correspondence, reporting, and user access complies with all State & Federal regulation and National Committee for Quality Assurance (NCQA) standards. Closely collaborates with subject matters experts (SMEs) to inform system configuration and workflow preferences. Provides system education and supporting documents to facilitate efficient and effective use of MM systems. Supports Sr. Manager and Assistant Manager, MM as CM SME in the development and implementation of CM functionalities (notes, assessments, turn-around-times, workflows). Performs periodic audits and quality assurance testing and system reviews as necessary and/or upon request of the leadership team. Monitors individual team member performance and provides mentoring and coaching as needed to promote consistent adherence to standards and shared ownership of quality outcomes. Maintains confidentiality in all aspects of Member, Health Options people and company information. Any other project work or supportive duties as assigned. JOB SPECIFIC KEY COMPETENCIES (KSAs) Appreciation of cultural diversity and sensitivity towards individual preferences. Ability to adapt and be nimble to effectively problem-solve complex, multifaceted, and/or emotionally charged situations. Proficient in English with verbal, written, interpersonal and public communications. Ability to function independently and proactively while actively pursuing knowledge and resources to manage daily work effectively and efficiently. Advanced skills in Microsoft Products and adaptability to varied electronic documentation systems. Must have excellent attention to detail with ability to act autonomously to maintain production levels and quality standards with minimal direct supervision. Ability to quickly prioritize and handle multiple projects at one time under tight deadlines. Excellent communication, writing, analytical and problem-solving skills. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Bachelor's degree in health-related field, preferred. 3-5 years of case management work experience required. Active CCM designation required. Active and unrestricted Compact or Maine RN licensure. Previous leadership experience required. REMOTE WORKERS: Must provide sufficient internet bandwidth to meet system operational needs and have a home office environment that protects the privacy and integrity of confidential information.

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. Job Posting TitleSenior Forecast Analyst - REMOTEJob Description The Senior Forecast Analyst is responsible for providing complex financial/data modeling, forecasting, revenue projections, and analysis for various functional areas throughout Prime as well as for the Pricing and Analytics team. This role is responsible for creating and developing new methodologies, reports, and analytical models and provide critical analysis related to Requests for Proposals (RFPs) and structure of client guarantees. Responsibilities Provide in-depth, comprehensive analysis and recommendations for the RFP process as Prime seeks to grow the business with purpose and bring in new groups and Blues plans Lead development and implementation of financial modeling changes to improve accuracy Consult with management and/or senior leadership to analyze and troubleshoot data analysis and/or forecasting issues for variety of complex projects Create, enhance, and maintain various forecasts and financial models, including but not limited to drug trend, generic discount projections, revenue forecasting, and RFPs; provide recommendations based on forecasts and analysis Mentor, coach, and provide work direction to more junior analysts on various work efforts Other duties as assigned Minimum Qualifications Bachelor's degree in Finance, Math, Economics, or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required 5 years of experience in detailed analytical work in financial, insurance, pharmacy benefits management, reporting & analytics, benefits consulting healthcare industries or related field Must be eligible to work in the United States without need for work visa or residency sponsorship Additional Qualifications Ability to work independently while maintaining accuracy and attention to detail and meet deadlines Excellent verbal and written communication and presentation skills to senior levels of leadership Proficiency in Microsoft Excel and/or database programming environment Demonstrated organization with the ability to balance multiple projects and meet competing deadlines Strong interpersonal skills with the ability to develop partnerships with internal clients Preferred Qualifications Extensive analysis and modeling experience with pharmacy, medical, insurance, and/or financial data Experience using SAS Enterprise Guide, SQL, or other related database programming environments Salesforce experience Previous work experience with model creation and maintenance Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $81,000.00 - $138,000.00 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Manager Rebate Contract Management - Remote **Job Description** The Manager of Rebate Contract Management oversees contracting, rate generation, reporting, and deliverables for State Medicaid supplemental rebate programs. This role collaborates with internal departments and external partners, including State Medicaid Programs and pharmaceutical manufacturers, to ensure strategic objectives and contractual obligations are met. This role is also responsible for resolving contract disputes and ensuring timely completion of monthly and quarterly deliverables. **Responsibilities** - Partner with internal teams (e.g., Rebate Operations, Account Management, Product Development, Preferred Drug List leadership and analytics) to respond to changing or emerging system initiatives and client implementations; actively participate in Request For Proposal (RFP) re-bid processes; perform research and analysis to identify and solve for operational business needs and enhancements - Manage the generation and execution of supplemental rebate agreements between Pharmaceutical Manufacturers, State Medicaid Programs and/or the company; Work with internal teams (e.g., Rebate Operations, Rebate IT, Preferred Drug List), as needed, for timely completion of contract/ product review cycles - Implement and oversee team's compliance with audit procedures, including participating in internal and external audits; develop and implement Standard Operating Procedures (SOPs) for each State process to support audit process - Provide oversight and direction for contract tracking, execution, rate generation, reporting, and deliverable processes using and modifying data queries and enhancing functionality of information systems - Develop and maintain professional working relationships with internal departments, State Medicaid Programs, and Pharmaceutical Manufacturers; may work with manufacturers on contract-related issues - Measure individual team member performance, balance workloads, and develop hiring plans to meet work needs; Helps to design and participate in programs to foster an environment of employee growth and opportunity - Accountable for team conduct and productivity and administer performance management to team members; identify on-going staff training and development opportunities to support continuous improvement and exceptional customer service - Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Finance or related area of study, or equivalent combination of education and/or relevant work experience; High school diploma from an accredited school or equivalent GED required + 6 years work experience in Medicaid, Compliance, or Contract Administration Management or related industry experience + 2 years of leadership/people management experience Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Ability to lead and manage others in a team environment + Basic technical proficiency and understanding of relational databases (Oracle, SQL Server and MS Access) and large data structures + Proficient in MS Word and Excel + Excellent verbal and written communication skills and ability to multi-task + Ability to establish relationships with new clients and pharmaceutical manufacturers as well as nurture relationships with existing clients/manufacturers + Understanding and application of contractual terms to teams operations **Preferred Qualifications** + Experience interacting with customers + Experience with rebate contracting and/or audits + Project management and implementation experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $81,000.00 - $138,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Network Management Consultant - Remote **Job Description** The Network Management Consultant is responsible for development, performance and management of Prime's retail, mail, specialty, and quality-based networks aligning with Prime's Supply Chain Cost of Goods Sold (COGS) and network management strategies. This includes development of network contracts, participation requirements, analysis of pharmacies, and ensuring contract and regulatory compliance. This position is accountable for creation and management of specialty fee schedules to ensure competitiveness and serves as the liaison between Prime's Network Management and Specialty teams. **Responsibilities** + Negotiate market competitive high-profile and/or complex pharmacy agreements across all channels including retail, mail, specialty and quality based and lines of business aligning with Supply Chain COGS strategies Lead and manage specialty fee schedule development process and ensure fee schedule revisions align with Supply Chains COGS strategies for specialty drug management + Lead and implement network initiatives by facilitating and performing network analyses, contracting activities and fee schedule development aligning with strategy, priorities and projects goals + Partner with Prime's reporting and analytics teams to develop network vendor loading rules inclusive of approved preferred and specialty pharmacies; maintain key compliance criteria and implement quarterly reporting processes for all contracted network specialty pharmacies + Analyze network specialty pharmacy quarterly reports to ensure compliance with reporting and participation requirements; collaborate with Specialty Clinical Program Directors to identify potential performance gaps; work with internal and external partners to develop and manage corrective action plans + Responsible for effectively managing the pharmacy contract from negotiation of all terms, ensuring Prime and Pharmacy compliance and document retention aligning with Prime's Record Information Management (RIM) policies + Work closely with Prime's legal team to update contract documents including agreements and applications for utilization in contracting/re-contracting activities based on new network participation requirements + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in business or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required + 8 years of Network Management experience within Pharmacy Benefit Management (PBM), healthcare or other highly regulated industry; including 5 years of managed care experience in medical or pharmacy network contracting Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Excellent verbal and written presentation skills + Demonstrated understanding of network reporting and analysis for specialty pharmacy + Demonstrated ability to establish trust and credibility; form working relationships with all levels of an organization + Demonstrated ability to work independently and on highly complex contract language and agreements; strong attention to detail + Enhanced organizational skills with the ability to work on multiple projects simultaneously + Demonstrated ability to problem solve and interpret complex data; ability to analyze network information and synthesize it into meaningful information for a variety for audiences + Ability to work with confidential data and maintain privacy **Preferred Qualifications** + Master's degree in business, healthcare or related area of study + Demonstrated understanding of retail and specialty network fee schedule management + 2 years of experience in specialty contracting + PBM and Healthcare experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. Job Posting TitleClinical Staff Pharmacist RemoteJob Description The Clinical Staff Pharmacist is responsible for the processing and documenting of Utilization Management requests (i.e. formulary exceptions, prior authorization, step therapy, quantity limit exceptions) for delegated products and services. Responsibilities Responsible for the clinical evaluation for coverage determination requests for prior authorization (PA) or other utilization management (UM) programs, including quantity limits, step therapy, formulary exception and tier exception; this includes consideration of the denial language and appropriateness of the decision as it pertains to the clinical content of the case and the intent of the individual client's pre-approved criteria Accountable for direct consultation with health care providers concerning non-formulary and clinical product coverage issues Collaborate with team members to promote consistency of decisions across the pharmacist team Other duties as assigned Minimum Qualifications Doctor of Pharmacy (PharmD) or Bachelor of Science Pharmacy Degree Current pharmacist license in good standing with the State Board of Pharmacy 1 year relevant work experience Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Excellent verbal and written communication skills Ability to work independently and as part of a team Preferred Qualifications Managed care experience Proficiency with Microsoft Office Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $51.92 - $88.46 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

The Manager, Quality and Accreditation is responsible for leading organizational quality improvement initiatives and ensuring ongoing compliance with accreditation and regulatory standards. This role oversees the development and facilitation of training strategies, manages quality data abstraction for NCQA HEDIS measures, CAHPS, and HOS surveys, and collaborates with internal stakeholders to close gaps and achieve performance targets. The Manager also coordinates accreditation readiness activities, ensuring policies, procedures, and operations meet or exceed standards set by NCQA, state, federal, and other governing bodies.This position plays a pivotal role in aligning operational performance with quality outcomes, supporting audit preparedness, and promoting a culture of compliance and continuous improvement across the organization. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Maintains strong working knowledge of National Committee for Quality Assurance (NCQA) Health Plan standards, MM department/ clinical policies and established workflows to inform quality assurance reviews, recommendations, and education. Oversee abstraction of NCQA HEDIS measures, CAHPS, and HOS surveys to monitor quality performance and identify gaps. Performs root cause analysis, identifying opportunities for improvement, implementing case-specific service recovery, and applicable corrective action plan of Member, provider, broker complaints related to internal MM services and delegated vendor services. Oversight of vendor related activities and relationships, ensuring vendor compliance with internal benchmarks, SLAs, and accreditation requirements. Tracks, monitors, and reports trends, impact, action, and outcomes of opportunities for improvement based on audit, complaint, IRR and appeal results. Analyze audit findings, develop corrective action plans, and collaborate with operational teams to improve outcomes. Timely submission of all applicable departmental policy/procedures, reports and updates. Ensures all applicable reports and updates are prepared for timely submission to applicable committees (Quality Assurance, Medical Management, Compliance, Complaints and Appeals). Manage annual policy and procedure reviews to ensure alignment with regulatory and accreditation requirements. Any other project work or supportive duties as assigned. JOB SPECIFIC KEY COMPETENCIES (KSAs) Direct experience with NCQA, URAC, CMS Stars, HEDIS, CAHPS, and HOS programs. Proven experience leading audits, accreditation surveys, and quality improvement initiatives. Able to work independently with minimal supervision. Ability to manage multiple priorities and meet tight deadlines in a fast-paced environment. Appreciation of cultural diversity and sensitivity towards individual preferences and needs of Member population. Proficient in English with verbal, written, interpersonal and public communications. Proficient with Microsoft Office products, typing, and ability to maintain accurate clinical documentation; ability to develop high quality reports for presentation to key internal/external stakeholders. Ability to maintain production levels and quality standards with minimal supervision. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Bachelor's Degree preferred. Minimum 3-5 years clinical experience, required. Unrestricted Compact or Maine registered nurse license, required.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting TitlePharmacy Claims Auditor - RemoteJob Description The Pharmacy Claims Auditor is responsible for identifying and evaluating potential waste and compliance through the pharmacy audit process and educating Prime's network pharmacies and driving contract compliance. This position will research, analyze and compile supporting information. This role will also execute and support audit-related projects, best practices in identifying audit trends, and business value opportunities for Prime and our clients. Responsibilities Conduct in-depth analysis of large datasets and audit findings to detect high-risk pharmacy claims, identify billing irregularities, and uncover patters of non-compliance or systemic errors Research and select appropriate audit samples strategically, prioritize pharmacy claims and providers for review based on risk indicators and compliance concerns Evaluate pharmacy claims and supporting documentation to determine whether claims align with contractual terms, provider manual policies, and applicable state/federal regulations Educate pharmacies on documentation standards and compliance best practices, while supporting accurate data and financial reimbursement to ensure appropriate claim corrections or reversals Other duties as assigned Minimum Qualifications Bachelor's degree in Health Science or related area of study, or equivalent combination of education and related work experience; High school diploma or GED required 2 years of work experience in retail, long term care, specialty, home infusion, or mail order pharmacy or combined pharmacy and Pharmacy Benefit Management experience to include 1 year of work experience in an operations, audit or quality assurance environment National Pharmacy Technician Certification through PTCB, ExCPT (CPhT) Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need while working with a high degree of autonomy Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients and other key stakeholders Ability to distill complex concepts or situations into concise and compelling communications Ability to interact positively and professionally during all pharmacy interactions and effectively de-escalate potentially confrontational situations Proficiency in MS Word, Excel, and database software Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment Preferred Qualifications 3 years of previous audit experience Current Registration with State Board of Pharmacy in the state where position is located Previous PBM experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $25.48 - $40.87 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** IT Manager **Job Description** The IT Manager of Data Engineering will lead with curiosity and will put people first. You'll remove barriers, grow people, and create space for smart engineers to do their best work. If you love asking great questions, turning ambiguity into clarity, serving your team so they can serve our members and partners, and a mindset of "No one works for me, I work for everyone on my team" you'll thrive here. We value transparency, trust, and continuous learning; we ship outcomes and we celebrate growth. This role partners with IT and business leadership to develop and execute technology strategies that drive quality, stability, and long-term sustainability. This position bridges strategic leadership with technical expertise and advances operational efficiency, innovation, and measurable business value. **Responsibilities** + Cultivate a productive and supportive work environment by providing professional development opportunities, clear objectives, and resources for staff effectiveness + Manage team performance through coaching, evaluation, and standardized performance metrics + Facilitate strong engagement with internal and external customers, addressing business needs, resolving issues, and delivering measurable value + Provide leadership across assigned IT ecosystem, ensuring stability, sustainability, and compliance with company standards, security, and financial policies + Align IT strategy with organizational goals, regulatory requirements, and best practices to promote long-term quality and efficiency + Collaborate across IT and business functions to identify solutions, improve execution, and drive innovation + Ensure accountability by monitoring performance against budget, resources, and development priorities + Support enterprise initiatives by implementing methodologies, services, and tools that enhance execution and productivity + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Information Systems or related area of study, or equivalent combination of education and/or relevant work experience; High School Diploma or GED equivalent required + 6 years of work experience in Information Technology (IT) + 2 years of leadership/people management experience **Additional Qualifications** + Excellent communication and stakeholder management skills to bridge technical and non-technical teams + Strong problem-solving and business analysis capabilities + Ability to lead teams through context switching, shifting priorities, and large-scale IT initiatives + Strong leadership and interpersonal skills, fostering collaboration in fast-paced, changing environments + Minimal travel on an as needed basis **Preferred Qualifications** + PBM / healthcare / regulated market company experience + Military leadership experience + Experience interfacing with executive level of leadership + Experience working in and leading teams within a fully remote environment + Advanced degree + Advanced certifications (e.g., PMP, CISSP, ITIL) strongly preferred Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $124,000.00 - $211,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

As a Payment Integrity Coder I, you will support the execution of Community Health Options claim payment accuracy strategy through performing complete claim reviews. You will collaborate with the payment integrity team to ensure existing programs, such as claim editing, are working correctly. This role will require coding experience, analytical skills, and solid communication and organizational adeptness. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing, pre-payment claims auditing, contract compliance, post-payment payment integrity solutions, etc. Review appropriateness of services/supplies billed with respect to the patient s medical condition and contemplate commercially reasonable claim-related edits to be applied in both pre- and post-pay situations. Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Coordinate with internal teams to maintain payment integrity solutions that increase claim payment accuracy. Frequently reviews other payer policies and procedures to identify gaps within the Health Options policy library, promotes areas of opportunity to appropriate stakeholders within the organization, and leads reimbursement specific policy development Participate in technology/tool updates, testing, and troubleshooting with internal teams and external vendors. Manage the scope of multiple inquiries, projects, or audits under minimal direct supervision. JOB SPECIFIC KEY COMPETENCIES (KSAs) Proven problem-solving skills - demonstrated ability to solve complex problems, which must consider long-term company-wide planning. Strong analytical skills - demonstrated ability to ensure reliability and relevance of data collected. Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. SQL and Datawarehouse query experience, preferred Excellent written communication skills - demonstrated ability to compose sensitive, non-routine correspondence requiring tact and diplomacy. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Bachelor s degree in business, healthcare administration, or other related functional area is required. 5+ years of experience working in health care hospital and physician practices and/or health insurance environment 3+ years of experience as a certified coder with a health plan, provider/hospital billing, or revenue cycle management. Certified Internal Auditor (CIA) preferred Certified Coding Specialist (CCS) A dedicated workspace with high-speed internet (=50 Mbps down / =10 Mbps up) and wired connectivity is required.

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. **Job Posting Title** Senior Compensation Analyst (Remote) **** The Senior Compensation Analyst is responsible for supporting or leading the development, implementation, communication, and administration of compensation plans including base pay and incentive programs, as well as policies and procedures for assigned groups. This role is responsible for competitive and consistent pay practices, compliance with federal and state regulations, including the Federal Labor Standards Act (FLSA) and pay transparency. **Responsibilities** + Educate and articulate the purpose and benefits of Prime's compensation philosophy and programs to Human Resources (HR) partners and people leaders to resolve compensation matters + Participate in, or lead incentive planning and design phases; accountable to administer and provide plan oversight for assigned incentive plans + Conduct moderate to complex data analysis to measure or compare competitiveness and effectiveness of Prime's compensation programs, and provide recommendations for enhancements and improvements to programs + Conduct job evaluations to determine the appropriate job title, pay grade, position level, and incentive level to ensure internal alignment and external market competitiveness, and conduct regular job classification audits (EEO, FLSA, etc.) to ensure accurate and compliant s and job classifications are maintained + Participate in annual market/salary surveys and maintaining market pricing tool + Partner with, and provide consultative support, to HR business partners on job evaluations, job descriptions, incentive plans and any other compensation related matters for assigned group(s) + Ensure compliance with applicable federal, state, and local compensation regulations and requirements and ensure alignment with payroll and timekeeping procedures + Other duties as assigned **Minimum Qualifications** + Bachelor's degree in Human Resources, Industrial Relations, Business or other related area of study, or equivalent combination of education and/or work experience; HS diploma or GED is required + 5 years of work experience in Compensation Must be eligible to work in the United States without the need for work visa or residency sponsorship **Additional Qualifications** + Ability to analyze data with a high level of accuracy and consistency + Ability to handle stressful situations with confidence and diplomacy + Demonstrated project management skills with the ability to work under strict timelines + Advanced Microsoft Excel and PowerPoint skills and proficiency with HR systems + Demonstrated confidence in presenting information to HR and management + Effective communication, negotiation and conflict resolution skills + Proven ability to build/maintain strong relationships **Preferred Qualifications** + Certified Compensation Professional (CCP) designation + Experience using Workday system + Experiencing supporting an IT Department or organization Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $81,000.00 - $138,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. Job Posting TitleManager Underwriting - REMOTEJob Description The Manager of Underwriting is responsible for managing the underwriting activities of a team of underwriters for existing clients at Prime Therapeutics. This position is responsible for serving as a consultant on matters pertaining to underwriting, performance guarantees, competitive pricing tactics, and other financial considerations. The Manager is also responsible for maintaining and applying knowledge of pricing strategies in the PBM industry. Responsibilities Oversees and coordinates workflow for the existing client underwriting group Manages a team of underwriters in support of the underwriting process; responsible for guidance and development of direct reports Coordinates modeling and tracking of revenue streams generated by existing clients Provides support to Sales and Client Engagement, assisting in the development of client presentations and negotiations pertaining to pricing and guarantees Engages with Sales and Client Engagement to provide input into the development of client specific pricing strategies Monitors trends and identifies the need for new or revised procedures and practices to achieve profit, sales and retention objectives Participates in development of methodologies, models, and reports to support objectives of the position Develops key internal relationships with business partners to ensure efficient and effective business processes and transactions Other duties as assigned Education & Experience Bachelor's degree in Mathematics, Accounting, Finance or related are of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required 6 years of related work experience and/or training 1 year of leadership/people management experience Must be eligible to work in the United States without need for work visa or residency sponsorship Additional Qualifications Knowledge of mathematical applications used in underwriting functions including the ability to calculate figures such as discounts, proportions and percentages, as well as the ability to apply basic concepts of business mathematics and algebra in underwriting problems. Ability to effectively present information and respond to questions in one-on-one or small group situations Excellent written and verbal communication skills Ability to communicate effectively with Senior Leadership Team Works well under stressful situations with competing deadlines and goals Ability to thrive working as an individual or in a team setting Preferred Qualifications 2 years of experience as a Senior Underwriter or Benefits Consultant PBM experience Physical Demands Constantly required to sit, use hands to handle or feel, talk and hear Frequently required to reach with hands and arms Occasionally required to stand, walk and stoop, kneel, and crouch Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. **Job Posting Title** Compliance Analyst Principal - Remote **Job Description** The Compliance Principal is responsible for the successful development, implementation and execution of the Regulatory Intelligence communication strategy. This position acts as Compliance and regulatory liaison for all lines of business with internal business partners responsible for account management and their clients and prepares regulatory related communications. **Responsibilities** + Promotes awarenessand communicationofcomplianceand regulatory change management initiatives with internal business partners and external clients and stakeholders + Partnerwith CorporateCommunications onvarious communicationactivities + Researches and responds to inquiries and questions from external clients and stakeholders + Actively participates inclient and stakeholder meetings + Reviews proposedfederal and state public policy and rule changes and prepares position papers for internal and external distribution Compliance Committee and the Compliance and Audit Committee and supports the Chief Compliance Officer's compliance governance responsibilities + Represents Compliance Regulatory Intelligence and Change Management teams in internal and external client and stakeholder meetings, preparing and presenting summaries and updates as needed + Accountable for ongoing external facing relationships as established for the purposes of compliance activities; ensure consultative and collaborative interactions with stakeholders in working through the regulatory change process + Supports new client implementations + Supports all lines of business (commercial/HIM, Medicare and Medicaid) + Other duties as assigned **Education & Experience** + Bachelor's degree in business, healthcare, or related area of study, or equivalent combination of education and/or relevant work experience; HS diploma or GED is required + 8 years of progressive work experience in legal or compliance related roles for a healthcare or Pharmacy Benefit Management organization, or within a highly regulated industry, including experience with Medicare, Medicaid, and the Affordable Care Act (ACA) + Must be eligible to work in the United States without need for work visa or residency sponsorship **Additional Qualifications** + Exceptional written and oral communication skills + Demonstrated ability to apply critical thinking skills to proactively identify issues and problem solve through the most complex compliance and ethics situations + Extensive experience assessing training requirements and developing, delivering and assessing effective enterprise compliance and ethics training programs through a variety of channels + Expert level understanding of effective compliance and ethics program principles, concepts, practices and standards; full breadth of knowledge around industry best practices and challenges and experience developing new concepts, techniques, standards and programs to support an organization's compliance and ethics priorities + Extensive experience establishing rapport and effectively influencing all levels within an organization + Advanced organizational skills with the ability to effectively work on multiple projects simultaneously **Preferred Qualifications** + Previous leadership/people management experience + PBM/health care experience + Certified Compliance and Ethics Professional (CCEP) or Certified Healthcare Compliance Professional (CHC) + Advanced degree in related area of study, such as Juris Doctor + Medicare Part D, Medicaid, and/or Affordable Care Act knowledge and experience **Physical Demands** + Ability to travel up to 20% of the time + Constantly required to sit, use hands to handle or feel, talk and hear + Frequently required to reach with hands and arms + Occasionally required to stand, walk and stoop, kneel, and crouch + Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds + Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $94,000.00 - $160,000.00 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (******************************************* and click on the "Benefits at a glance" button for more detail. _Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to_ _race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law._ _ _ _We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law._ _Prime Therapeutics LLC is a Tobacco-Free Workplace employer._ Positions will be posted for a minimum of five consecutive workdays. At Prime Therapeutics (Prime), we are a different kind of PBM. We're reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at ************** or email *****************************.

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. Job Posting TitleSolution Product Owner, SharePoint - RemoteJob Description The Solution Product Consultant is responsible for support of the product development team in their delivery of value-added solutions to business problems, working closely with the Product Owner role. They provide key operational knowledge to assist in building of appropriate backlog, validate outcomes and accept user stories, work with clients on change configuration needs and support operational team change needs. Responsibilities Represent assigned product in the development of user stories, acceptance criteria, operational processes, client configurations and process change Act as the primacy point of contact for internal and external resources on business knowledge related to the operational processes, configuration and needs of the product Conduct testing for acceptance of user stories and configuration changes; including creation of test cases, performance of User Acceptance Testing (UAT) and Joint Cycle Testing activities Work with the product owners and operations teams to understand product discovery/definition and convert to actionable items on the backlog; user story creation, definition of acceptance criteria and loading into the feature/requirement tracking tool Other duties as assigned Minimum Qualifications Bachelor's degree in Business, IT, Healthcare Administration or related area of study, or equivalent combination of education and/or relevant work experience 2 years of work experience in supporting business process or system change and/or similar relevant experience Must be eligible to work in the United States without need for work visa or residency sponsorship Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications Ability to establish and maintain relationships with clients Self learns new processes / software to solve analytic problems Interpersonal skills necessary to drive results and deliver on commitments Experienced at meeting facilitation, conflict management, and consensus building Preferred Qualifications Experience working in an agile environment Experience in Pharmacy Benefit Management (PBM) or related industry Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $81,000.00 - $138,000.00 based on experience and skills.To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

The Policy and Coding Research Specialist, reporting to the Sr. Manager of Utilization Management, Care Management and Quality and working closely with the Senior Medical Director and the Coding and Configuration Manager. The candidate is responsible for providing essential support and information that translates evidence-based medical care into policies and procedures that enable a health plan to function. They will be responsible for reviewing clinical, regulatory and industry resources to maintain knowledge about new and emerging technologies and treatments, payor standards for coverage in similar markets and new CPT and ICD-10/11 and HCPCS codes for configuration and coverage assignment. This job is remote and requires meticulous work, often self-directed. Collaboration with other members of the team and within the organization is key to success in this role. There is opportunity for growth in the role. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Research Reviews clinical resources and external health plan policies for coverage comparisons Supports review of CMS-designated codes, coding updates and does timely review of codes initially designated as exclude at launch or experimental/investigational to determine required code designations. Works closely with the Coding and Configuration Manager to accomplish this. Does research needed for custom code-configuration lists, such as the Chronic Illness Support Program, to support all lines of business and self-insured employer groups benefit coverage requirements, as applicable. Monitors regulatory requirements to ensure appropriate code configuration and coverage. Collaboration Is part of the Utilization Management Team that supports and collaborates with the Clinical Operations Team to ensure appropriate configuration of codes for billing and auditing. Participates in the Clinical Code Review, Benefits and other Committees as requested. Works with Compliance Team to meet regulatory requirements and stay up to date on legislative initiatives. Maintenance Is responsible for updating policies and guidelines within MCG and maintains the license and relationship with our vendor partner. Maintains the licenses and communication with Hayes (symplr) Medical Necessity Guidelines. Maintains expert knowledge of ICD-10 and 11, CPT and HCPCS codes and provides education as necessary. Understands current Member Benefit Agreements for all lines of business. Other Duties Willingness to support the Utilization Management team with case reviews as needed to maintain compliance. Willingness to participate in project work or supportive duties as assigned by the Director of Utilization Management, Care Management and UM Appeals, the Coding and Configuration Manager, or Senior Medical Director. JOB SPECIFIC KEY COMPETENCIES (KSAs) Proficient in Microsoft Products, particularly Word and Excel and adaptability to use electronic documentation systems, including Salesforce. Excellent English communication and writing skills. Familiarity with application of MCG Guidelines. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces: Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. QUALIFICATIONS AND CORE REQUIREMENTS Valid, unrestricted RN (registered nurse) Licensure, Compact or Maine Licensed. Minimum of 3 years working in a health plan with relevant experience. 2+ years of policy research and development experience. Experience in medical necessity reviews within a health plan highly preferred. Certified coder, or certification within 6-12 months of hire. #LI-Remote