Claims Consultant

The Claims Consultant supports the administration and processing of pharmacy benefit claims for self-funded employer health plans. This role serves as a key liaison between clients, plan members, pharmacies, pharmacy benefit managers (PBMs), third-party administrators (TPAs), and internal teams to ensure claims are processed accurately, efficiently, and in accordance with plan provisions and regulatory requirements. The Claims Consultant plays a critical role in analyzing claim issues, resolving discrepancies, identifying cost-saving opportunities, and delivering exceptional service to clients and stakeholders.

This position contributes directly to ARORx's mission of helping self-funded organizations optimize pharmacy benefits, manage costs, and improve plan performance.

• Review, investigate, and resolve pharmacy benefit claim issues and inquiries in a timely manner.
• Analyze claim adjudication outcomes and identify discrepancies, processing errors, and opportunities for corrective action.
• Coordinate with pharmacies, PBMs, TPAs, carriers, brokers, and plan sponsors to resolve complex claim concerns.
• Research eligibility, benefit design, prior authorization requirements, and plan provisions to determine claim outcomes.
• Monitor claim payment accuracy and compliance with contractual and regulatory requirements.
• Assist in the auditing and reconciliation of pharmacy claims data.
• Support client implementation projects and benefit plan changes.
• Maintain accurate documentation of claim investigations, resolutions, and communications.
• Partner with Account Management, Clinical, and Operations teams to ensure seamless service delivery.
• Provide education and guidance to members regarding claim processes, pharmacy benefits, and cost management strategies.
• Stay current on pharmacy benefit trends, industry regulations, and healthcare legislation impacting claims administration.
• Other duties as assigned.
• Education/
  
  Experience:
• Bachelor’s degree in business, Healthcare Administration, Finance, Insurance, Public Health, or a related field preferred.
• Minimum of 3 years of experience in health insurance, pharmacy benefits, claims administration, healthcare operations, or related industry experience.
• Experience working with self-funded health plans, PBMs, TPAs, or pharmacy benefit programs preferred.
• Equivalent combination of education and experience may be considered.
• Strong verbal and written communication skills.
• Bilingual (English/Spanish) preferred, with the ability to effectively communicate with Spanish-speaking members, clients, pharmacies, and business partners to provide exceptional service and support.
• Knowledge, Skills, and Abilities
• Strong understanding of healthcare claims, processing and pharmacy benefit administration.
• Knowledge of prescription drug benefit structures, formularies, specialty pharmacy programs, and utilization management processes.
• Excellent analytical and problem-solving skills with the ability to investigate complex claim issues, identify root causes, and determine appropriate resolutions.
• Demonstrate the ability to independently assess urgency, prioritize responsibilities, research and resolve issues using available resources, determining next steps before escalation, and ensuring timely follow up, appropriate escalation, and clear communication.
• Advanced attention to detail and commitment to accuracy.
• Strong customer service and relationship management skills.
• Ability to communicate professionally with members, pharmacies, providers, and internal teams.
• Proficiency in Microsoft Office Suite, particularly Excel.
• Experience working with claims adjudication systems, reporting platforms, and healthcare data preferred.
• Strong learning agility and adaptability, with the ability to quickly learn new processes, systems, client requirements, and pharmacy benefit programs and effectively adapt to procedural, operational, or organizational changes.
• Strong organizational and documentation skills.

Candidates should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

At Acrisure, we’re building more than a business, we’re building a community where people can grow, thrive, and make an impact. Our benefits are designed to support every dimension of your life, from your health and finances to your family and future.

Making a lasting impact on the communities it serves, Acrisure has pledged more than $22 million through its partnerships with Corewell Health Helen DeVos…