Associate Director, Network Pricing - Drug Pricing & Claims Integrity -Remote2369529 | Eden Prairie, Minnesota

Associate Director, Drug Pricing & Claims Integrity

Optum Rx is looking for a curious, adaptable, and self-motivated Associate Director to be part of our Network Pricing team. This is an advanced analytics role where you will learn and apply the business fundamentals of drug pricing, claims adjudication platform logic, the underlying data flows, and the tools and systems used in this type of financial analysis. The person in this role will work with and have regular exposure to analysts and projects in our global data science and network pricing teams.

The role partners closely with Network Contracting, Pricing, Technology, Compliance, and Operations teams to ensure that contract terms, reimbursement methodologies, and regulatory requirements are correctly translated into adjudication logic and consistently executed at the point of sale.

Position

Description:

Supports and validates unit cost management activities through financial and network pricing modeling, analysis, and reporting. This role is responsible for ensuring accurate pharmaceutical drug pricing and claims adjudication across the pharmacy network by validating pricing logic, adjudication configuration, and contractual compliance within the claims platform (RxClaim). The position focuses on identifying, researching, and correcting claims pricing discrepancies, coding or configuration errors, and pharmacy contract misalignment, with specific accountability for Medicare and CMS compliance requirements, including Plan Finder accuracy.

Primary Responsibilities:

• Own end-to-end accountability for prescription drug pricing accuracy and claims adjudication outcomes, from pricing strategy and financial modeling through configuration, validation, and ongoing monitoring
• Develop and maintain financial models to support drug pricing strategy, unit cost targets, reimbursement methodologies, and performance analysis
• Set and validate drug pricing parameters to ensure accurate execution of pharmacy contracts, reimbursement logic, and benefit design within the adjudication platform (RxClaim)
• Identify, research, and resolve claims pricing discrepancies, including incorrect reimbursement or misconfiguration of pricing and adjudication logic
• Perform claims research, adjustments, and corrections as appropriate; identify patterns or systemic issues requiring broader remediation
• Interpret pharmacy contracts and ensure contractual terms are accurately translated into adjudication logic, identifying gaps between negotiated terms and live claims behavior
• Ensure adherence to state and federal regulatory requirements, including CMS and Medicare (Plan Finder) pricing and compliance standards, and support remediation of identified issues
• Partner with network, pricing, compliance, analytics, and technology teams to validate assumptions, resolve issues, and deploy accurate, compliant pricing solutions
• Communicate complex pricing, adjudication, and compliance findings clearly to technical and non-technical stakeholders, including senior leadership
• Establish and maintain repeatable workflows, documentation, and internal controls to support compliant, scalable pricing logic and adjudication configuration
• Provide guidance and direction to team members, as applicable, and lead cross-functional initiatives impacting pricing accuracy and claims integrity

Required Qualifications:

• 7+ years of experience in pharmaceutical pricing, claims adjudication, healthcare financial modeling, or PBM operations
• Solid analytical skills with experience building and validating financial models, pricing validations, or audit controls
• PBM experience
• Proven ability to interpret contracts, reimbursement methodologies, and pricing guarantees
• Proven ability to understand end-to-end claims or data workflows and diagnose anomalies across pricing, configuration, and process
• Proven excellent written and verbal communication skills, with the ability to clearly explain complex pricing and adjudication issues to diverse audiences

Preferred Qualifications:

• Direct experience with RxClaim or a comparable pharmacy claims adjudication platform
• Experience designing or executing claims audits, pricing QA, or compliance…