Research Specialist Lead - Govt Programs - Remote

Prime Therapeutics LLC

Job Overview

Location

Home

Job Type

Full-time

Full Job Description

📋 Description

• The Research Specialist Lead - Govt Programs - Remote role at Prime Therapeutics is a critical position focused on resolving member concerns and ensuring accurate claims processing within government healthcare programs, directly impacting member satisfaction and compliance with regulatory standards.
• This role serves as a subject matter expert in government benefit plans, particularly Medicare and Medicaid, and supports internal and external partners by researching complex issues, providing timely resolutions, and driving process improvements that enhance operational efficiency and client trust.
• Day-to-day responsibilities include utilizing Prime’s internal systems (such as RxClaims, Salesforce, and Confluence) to conduct thorough research on member inquiries and escalated issues from internal teams, pharmacies, and external clients, ensuring timely and accurate responses within established turnaround times.
• The specialist provides detailed information about benefit plans to members, clients, and pharmacy support teams to prevent claim denials, resolve discrepancies, and ensure accurate adjudication of prescriptions under government programs.
• Communication of issue resolution results is performed per standard operating procedures, including formal written correspondence to members and clients, maintaining clarity, professionalism, and compliance with regulatory requirements.
• Acting as a subject matter expert (SME), the role involves assisting with technical questions, guiding workflow or process direction, coordinating peer letter reviews, and mentoring peers on complex case handling and documentation best practices.
• Collaboration with supervisors to identify process and quality improvement opportunities is expected, including participating in solution implementation, supporting special projects, and contributing to team-level initiatives aimed at reducing errors and enhancing service delivery.
• The role requires completion of accurate reporting as requested, tracking key metrics such as resolution times, escalation trends, and KPI performance to support data-driven decision-making and continuous improvement.
• The position demands strong self-motivation and the ability to work with minimal supervision while managing multiple priorities under strict timelines, consistently exceeding established Key Performance Indicators (KPIs) for quality, accuracy, and timeliness.
• Success in this role requires strong organizational, analytical, interpretive, and problem-solving skills, coupled with the ability to make consistent, unbiased decisions based on complex benefit plan rules and regulatory guidelines.
• Excellent verbal and written communication skills are essential, particularly in drafting formal business letters and explaining intricate benefit structures to diverse audiences, including members, providers, and internal stakeholders.
• Interpersonal strengths in conflict resolution, active listening, and interdepartmental collaboration are vital for navigating sensitive member concerns and aligning resources across teams to achieve resolution.
• The role offers significant opportunity to develop deep expertise in government healthcare programs, particularly Medicare and Medicaid, within the PBM industry, building a specialized skill set highly valued in healthcare operations and regulatory compliance.
• Individuals in this position can advance their careers by gaining exposure to process improvement methodologies, leadership coordination, and cross-functional project work, positioning them for future roles in supervision, training, or program management within Prime Therapeutics’ government programs division.

🎯 Requirements

• High School diploma or equivalent GED
• 4 years of work experience in customer service, benefit plans, grievances, or appeals in the Medicare space, preferably within a PBM environment
• Strong organizational, analytical, interpretive, problem-solving, and time management skills with the ability to work under strict timelines and manage competing priorities
• Strong verbal and written communication skills, including formal business letter writing, and interpersonal abilities in conflict resolution and active listening
• Ability to be self-motivated and work with minimal supervision while exceeding established Key Performance Indicators (KPIs)
• Eligibility to work in the United States without the need for work visa or residency sponsorship

🏖️ Benefits

• Access to Prime Therapeutics’ comprehensive benefits package, including health, dental, and vision insurance, as detailed on the company’s Benefits Page
• Opportunities for professional development and skill enhancement through exposure to government programs, internal systems (RxClaims, Salesforce, Confluence), and process improvement initiatives
• Remote work flexibility enabling a balanced work-life arrangement while contributing to meaningful healthcare outcomes for members served under government programs

Skills & Technologies

Senior

Remote

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Prime Therapeutics LLC

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About Prime Therapeutics LLC

Prime Therapeutics LLC is a pharmacy benefit management company founded in 1989 and headquartered in Eagan, Minnesota. It administers prescription drug plans on behalf of health plans, employers, and government programs, processing claims, negotiating rebates, managing formularies, and operating specialty pharmacies. Owned by a consortium of Blue Cross and Blue Shield plans, the company serves over 40 million members nationwide while focusing on cost control, clinical outcomes, and member safety.

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