Founded in 2019 and headquartered in Pittsburgh, PA, Free Market Health supports forward-thinking payers and specialty pharmacies of all sizes who need to operate in a complex and opaque market. We empower all stakeholders to optimize resources and maximize opportunities while focusing on the most important stakeholder of all: the patient.

Overview 

As part of the Platform Support team at Free Market Health, the Manager, Claims Support is responsible for the stewardship of healthcare claims-related operations across the enterprise. The ideal candidate has a deep understanding of and experience with healthcare claims transactions (both medical and pharmacy) and can lead a team charged with ensuring the accurate and reliable management of claims-related activities across multiple business units within the organization.  

As part of a growing team in a fast-paced environment, we are looking for a Manager, Claims  Support will bring their expertise to a team that values collaboration, and a passion for accuracy and reliability in support of our mission to never let the process fail the patient. 

Specifics   

The specific responsibilities for this role include, but are not limited to: 

• Manage a small team of claims analysts to support medical and pharmacy claims activity  

• Oversee operation of the medical claims clearinghouse 

• Support the needs of new and existing Payers & Pharmacies for medical and pharmacy claim submissions 

• Manage and resolve all claim payment issue escalations from Pharmacies across both medical and pharmacy claims. 

• Collaborate closely with Referral Support, Intake Support, Pharmacy Services, Client Services and Finance teams to utilize existing claim data to streamline and automate processes, and promote claim payment accuracy 

• Problem-solve with Technology Services and Software Engineering Teams to support the technical aspects of claims-related activities 

• Coordinate with FMH payer clients regarding claim-level reconciliation, including the resolution of payment issues on behalf of FMH customers 

• Partner with internal teams to resolve systematic payment issues resulting from Payer/PBM set up issues. 

• Develop and operationalize bi-weekly process for Pharmacies to rebill claims which were paid at the wrong rate. 

• Develop and measure KPIs  

• A commitment to protecting the confidentiality and security of sensitive healthcare information in accordance with HIPAA.  

• As this is a highly collaborative role, onsite work at our Pittsburgh Headquarters is required. Occasional travel to professional events or meetings required. 

Qualifications 

• Bachelor’s degree in business, pharmacy, healthcare management, or similar 

• 7+ years of experience in Pharmacy, Healthcare, or Operations with healthcare claims and related transactions with a thorough understanding of both pharmacy and medical claims processes 

• 2-3 years prior team leadership or management experience 

• Experience working with NCPDP, X12, or other standards organizations in the healthcare space 

• Proficiency with MS Office Suite and SQL 

• Proficiency with various resources and formats, including FHIR, XML, and JSON is preferred 

• Strong communication, problem-solving, and organizational skills to manage complex transaction sequences across multiple business units