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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims adjudication, including eligibility, coverage rules, and pricing, while effectively managing cross-functional teams and driving product strategy in a regulated healthcare environment. Proven ability to lead platform migrations and ensure compliance with operational and regulatory standards.
Highest-signal resume keywords
Claims Adjudication ExpertiseProduct Management ExperienceCross-Functional LeadershipAgile Methodology ProficiencyRegulatory Compliance Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims Processing SystemsPlatform MigrationKPI TrackingUser Story WritingAcceptance Criteria DefinitionTesting and CertificationData ManagementPharmacy Data StandardsSystem IntegrationTransaction Processing
Soft Skills
Strong CommunicationDetail OrientedProcess FocusedCurious and AdaptableIndependent Execution
Tools & Technologies
APIsHealthcare Data PlatformsAgile Tools
Certifications & Qualifications
Bachelor's DegreeAdvanced Degree (MBA, MPH, or Technical Degree)
Industry Keywords
Pharmacy Benefit Managers (PBMs)MedicareHealthcare RegulationsPharmacy ClaimsBenefit Administration
About the role
Key responsibilities & impact- Own the vision, roadmap, and delivery plan for claims adjudication, including how it scales with volume, new clients, and new lines of business
- Build deep expertise in pharmacy claims adjudication across eligibility, coverage rules, pricing, rejections, overrides, and coordination of benefits, and turn it into a structured, prioritized plan
- Define the long-term strategy for platform evolution to support operational scale, regulatory requirements, and new lines of business, including Medicare
- Write specs, user stories, and acceptance criteria; lead backlog refinement, sprint planning, and release coordination in an agile environment
- Partner with the adjudication engineering team to sequence work, manage dependencies, and resolve ambiguity in claim behavior
- Set correctness standards and own testing and claim certification to prove production readiness
- Own readiness and rollout planning, including validation against real claim volume, parallel testing, and phased release
- Coordinate go-live readiness across operations, clinical, client success, and compliance
- Partner with PBM operations, clinical, legal, and client success teams to meet workflow and regulatory requirements
- Manage drug data, formulary, and prior authorization dependencies
- Define and track KPIs for claim accuracy, system performance, and reliability
- Act as the primary product point of contact for adjudication across the organization and with external partners
Requirements
What you’ll need- Bachelor's degree required
- 5 or more years of product management experience, preferably in healthcare or enterprise technology
- Experience with complex, rules-driven transaction processing systems such as claims adjudication, payments, or benefit administration, including responsibility for correctness and testing
- Experience leading a platform migration or major system transition from requirements through go-live
- Proven ability to lead cross-functional initiatives involving product, engineering, legal, and operations stakeholders
- Ability to work independently and drive execution with minimal direction
- Strong communicator who collaborates well across technical and non-technical teams
- Detail oriented and process focused, and comfortable in a domain where correctness is measured claim by claim
- Comfortable working across complex, data-heavy systems
- Curious and adaptable, willing to dig into unfamiliar and highly technical territory and find answers
- Experience working in or with PBMs, pharmacy claims, or pharmacy operations is a plus
- Familiarity with systems that support regulated healthcare markets, including Medicare, is a plus
- Knowledge of pharmacy-related data standards such as NCPDP or Medi-Span is a plus
- Exposure to APIs, system integrations, or healthcare data platforms is a plus
- An advanced degree in a relevant field (MBA, MPH, or a technical degree) is a plus
Benefits
Comp & perks- Bonus
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