Senior Product Manager, PBM Claims Adjudication Platform

Quick Facts

• Role: Senior Product Manager (Claims Adjudication)
• Domain: PBM platform for pharmacy claim processing

Description

Own the vision, roadmap, and delivery plan for claims adjudication—the core system powering the full lifecycle of a pharmacy claim, including eligibility, coverage, pricing, rejections, overrides, and coordination of benefits. Develop expertise based on real claim behavior to define where the platform goes next, write precise requirements for engineering and QA, and set the correctness bar with a validation/certification approach ready for production volume. Operate independently and lead cross-functional execution across product, engineering, operations, clinical, and compliance.

Responsibilities

• Own strategy, roadmap, and delivery plan for claims adjudication and scaling for volume, new clients, and new lines of business
• Translate deep knowledge of pharmacy claim adjudication into a structured, prioritized plan across eligibility, coverage, pricing, rejections, overrides, and coordination of benefits
• Define long-term platform strategy to support operational scale, regulatory requirements, and new lines of business (including Medicare)
• Write clear specs, user stories, and acceptance criteria; lead backlog refinement, sprint planning, and release coordination in an agile environment
• Partner daily with adjudication engineering to sequence work, manage dependencies, and resolve ambiguity in claim behavior
• Own correctness standards, including the testing and claim certification approach for production readiness
• Own readiness and rollout planning, including validation against real claim volume, parallel testing, and phased release
• Coordinate go-live readiness across operations, clinical, client success, and compliance so changes land without disruption
• Partner with PBM operations, clinical, legal, and client success to ensure workflow and regulatory requirements are met
• Manage drug data, formulary, and prior authorization dependencies; collaborate with internal owning teams as key partners
• Define and track KPIs for claim accuracy, system performance, and reliability
• Act as the primary product point of contact for adjudication across the organization and with external partners

Requirements

• Bachelor’s degree
• 5+ years of product management experience, preferably in healthcare or enterprise technology
• Experience with complex, rules-driven transaction processing systems (claims adjudication/payments/benefit administration) with responsibility for correctness and testing
• Experience leading platform migration or major system transition from requirements through go-live
• Proven ability to lead cross-functional initiatives across product, engineering, legal, and operations
• Ability to work independently and drive execution with minimal direction
• Strong communication skills across technical and non-technical teams
• Detail-oriented, process-focused, and comfortable with claim-by-claim correctness
• Comfort working across complex, data-heavy systems

Benefits

• Compensation: $150,000–$195,000 annually, plus bonus and equity
• Compensation may vary by geographic location, experience, and qualifications