AVP, Darwin Claims Operations

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare.  We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

Providing high quality services to clients and beneficiaries is at the core of what we do every day! The PBM Operations & Services team is the very heart of Abarca’s operations, responsible for delivering high performing clinical programs, pharmacy claims configurations, claim reprocessing, call center services, government services and beyond. The Darwin Claims Operations team handles all claims verifications, day to day configuration set-up and maintenance as well as related special projects, issue management and research for configuration.

 As AVP for Darwin Claims Operations you’ll be dedicated to supporting how we configure the platform for our clients. The Darwin Claims Operations team is responsible for initial set-up, quality, and maintenance of the benefit, pharmacy network, pricing, reprocessing and formulary design and system logic configurations as defined and documented by our clients. The AVP is responsible for leading and strategically managing all aspects of claims processing within the organization to ensure excellence at the point of service. Part of the job is to continuously evaluate processes to improve where possible, develop team members and their objectives, and establish metrics to measure the productivity and quality of your team. 

The fundamentals for the job…

• Defines strategy, reviews, and collaborates on the creation of OKRs (Objectives, Key, Results) and monitor progress of set goals.
• Accountable for Darwin Clams Operations performance quality and results for individuals and the overall team
•  Establish metrics to measure the productivity and quality of the DARWIN Claim Operations Team
• Foster and develop DARWIN platform SMEs.
• Conduct performance reviews, quarterly/semiannual check-ins, and staff meetings to guide performance management and employee development efforts and direct them toward departmental goals, including quality and process improvement efforts.
• Serve as an integral part of the organization’s leadership team to help strategically plan for growth and develop ways to increase the optimal operational efficiencies and quality of claims processing at point of service.
• Collaborate with cross-functional teams to plan and execute projects and to deliver the highest quality of service for all clients and partners.
• Maintain a standard of continuous process improvement, including setting up the necessary control mechanisms for issue escalation.
• Ensure The DARWIN configuration team reads and understands the DARWIN documentation releases that include any system changes or new functionalities that could impact compliance with CMS and state regulations and/or benefit design.
• Establish and cultivate teamwork, communication, and accountability.

 

 What we expect of you

The bold requirements…

• Bachelor’s Degree or master’s degree in business administration, Healthcare or a related area (in lieu of a degree equivalent experience can be considered)
• 12+ years of experience in a leadership role in the PBM or Insurance industries.
• Experience with PBM business: Operations and external regulator guidelines (such as Medicare, Medicaid, and state requirements).
• Experience leading teams within the pharmacy claims management and configuration arenas.
• Experience with dashboard tools, such as Power BI and Excel tools.
• Experience with handling multiple projects at once in collaboration with internal and external stakeholders.
• Excellent verbal and written communication skills (bilingual fluency in both Spanish and English is a plus).
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves.  We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local la