About this role
Accountabilities: Client, Consultant, and Vendor Relations: Act as a primary point of contact for member-related issues, ensuring clear communication, proactive updates, and timely resolution. Lead issue review meetings, prepare detailed resolution summaries, manage challenging conversations with professionalism and empathy, and present performance trends and improvement initiatives during business reviews. Member Issue Resolution and Escalation Management: Prioritize cases according to urgency and member impact, particularly when medication access is at risk. Serve as the final internal escalation point for complex cases involving members, pharmacies, prescribers, and payers. Coordinate with internal teams and external partners to resolve issues, verify outcomes, maintain service-level agreements (SLAs), and improve workflows that affect medication access and member services. Root Cause Analysis and Continuous Improvement: Investigate complaints, escalations, incidents, and quality failures using structured methodologies such as the 5 Whys, fishbone diagrams, Pareto analysis, and process mapping. Identify and validate underlying issues related to processes, systems, data, policies, vendors, or training. Develop and oversee corrective and preventive action (CAPA) plans, establish measurable success criteria, and ensure improvements are implemented and sustained. Quality Assurance and Compliance: Lead quality monitoring activities, including call and case audits, scorecard development, evaluator calibration, and constructive performance feedback. Ensure adherence to internal policies, contractual obligations, HIPAA requirements, and applicable healthcare regulations. Support internal, external, and client audits, translating quality findings into training initiatives, updated standard operating procedures (SOPs), and practical job aids. AI Tool Oversight and Optimization: Act as the team's subject matter expert for AI-powered tools, guiding employees in their effective use. Review AI-assisted interactions for accuracy, quality, and compliance, collaborate with technology teams to improve performance, and identify automation opportunities that reduce recurring issues and strengthen operational consistency. Team Leadership and Performance Management: Coach and develop team leads and staff, oversee scheduling and performance objectives, conduct performance reviews, and foster a culture of accountability, continuous learning, and member-first service. Reporting and Cross-Functional Collaboration: Monitor and report key performance indicators, including issue volume, resolution times, SLA compliance, repeat incidents, and member satisfaction. Deliver data-driven insights to leadership, track corrective action progress, identify emerging risks, and collaborate across functions to improve overall Member Experience operations as business needs evolve. Requirements Relevant Professional Experience: At least 3 years of experience in member experience, pharmacy benefit management (PBM), pharmacy claims, or related healthcare operations. People Management Experience: At least 2 years of experience managing teams in a queue-based or contact center environment, including responsibility for escalations, quality assurance, or operational performance. Client-Facing Communication: Demonstrated experience resolving member-facing issues directly with clients, consultants, or vendors, including explaining root causes, communicating outcomes, and managing expectations. Root Cause Analysis: Proven ability to investigate complex operational problems, identify underlying causes, and implement sustainable corrective actions supported by measurable results. Healthcare and Regulatory Knowledge: Working knowledge of prior authorization, coordination of benefits, pharmacy claim rejections, and HIPAA requirements. Technical Proficiency: Experience using CRM platforms or claims management systems, along with strong Microsoft Excel skills, including pivot tables. Education: High school diploma or equivalent required. A bachelor's degree in healthcare administration, business administration, or a related discipline is preferred. Additional Industry Experience: Experience in specialty pharmacy, mail-order pharmacy, or long-term care settings is an advantage. Experience presenting operational insights and improvement plans to clients or executive stakeholders is also preferred. Analytical and Problem-Solving Skills: Strong investigative mindset, attention to detail, and ability to use data to identify trends, assess risks, and distinguish symptoms from underlying causes. Communication and Relationship Management: Excellent written and verbal communication skills, with the ability to explain complex issues clearly, handle difficult conversations with composure, and build trust with diverse stakeholders. Leadership and Accountability: Strong coaching, team development, decision-making, and organizational skills, with a demonstrated commitment to following issues and corrective actions through to verified resolution. Adaptability and Operational Judgment: Ability to prioritize competing demands, make sound decisions under pressure, and take on evolving responsibilities in a growing healthcare organization. Work Environment and Availability: Comfortable working remotely with extended computer and phone use. Willingness to participate in on-call coverage for urgent escalations, accommodate occasional extended hours and partner calls outside standard business hours, and travel occasionally for meetings, training, or client and vendor visits. Work Authorization: Applicants must be legally authorized to work full-time in the United States without requiring employer sponsorship, visa transfer support, or other employer-provided immigration-related employment authorization, either now or in the future. Benefits Competitive Compensation: Annual base salary of $75,000–$85,000, depending on qualifications and experience. Performance Incentives: Eligibility for a bonus in addition to base compensation. Health Coverage: Access to health benefits. Retirement Planning: 401(k) plan with an employer match. Equity Opportunity: Stock options. Paid Time Off: PTO to support personal needs and work-life balance. Remote Flexibility: Remote work arrangement within the United States. Meaningful Impact: Opportunity to improve member experiences, support medication access, and contribute to better healthcare outcomes. Innovation and Growth: Work in a collaborative, fast-moving, technology-driven environment with opportunities to contribute to process improvements and evolving operational initiatives. How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether? Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time. #LI-CL1
- LOCATION
- Remote · US, United States
- WORK MODE
- Remote
- JOB TYPE
- Full-time
- POSTED
- Oct 29, 2026
Source: Jobgether Careers