Jobbörse

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

OptumRx is looking for a curious, adaptable, and self-motivated Associate Director to be part of our Network Pricing team as a leader in Drug Pricing & Claims Integrity. 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.

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.

You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

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

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Years of post-high school education can be substituted/is equivalent to years of experience.

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
• 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

Preferred Qualifications:

• Prior PBM experience
• Experience supporting Medicare Part D, CMS reporting, or Medicare Plan Finder pricing accuracy
• Direct experience with RxClaim or a comparable pharmacy claims adjudication platform
• Experience designing or executing claims audits, pricing QA, or compliance validation frameworks
• Excellent written and verbal communication skills, with the ability to clearly explain complex pricing and adjudication issues to diverse audiences

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $112,700 to $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.