Lead Pharmacy Systems Operations Specialist

GoodRx is the leading prescription savings platform in the U.S. Trusted by more than 25 million consumers and 750,000 healthcare professionals annually, GoodRx provides access to savings and affordability options for generic and brand-name medications at more than 70,000 pharmacies nationwide, as well as comprehensive healthcare research and information. Since 2011, GoodRx has helped consumers save nearly $75 billion on the cost of their prescriptions.

Our goal is to help Americans find convenient and affordable healthcare. We offer solutions for consumers, employers, health plans, and anyone else who shares our desire to provide affordable prescriptions to all Americans.

About the Role:

The Lead Pharmacy Systems Operations Specialist will be responsible for managing the pharmacy system adjudication of GoodRx and Scriptcycle Retailer Programs on the pharmacy claims adjudication platform. The ideal candidate will have a background in pharmacy adjudication and analytics and have a skillset that is a balanced mix of analytical and problem solving skills. Projects will require close teamwork with pricing leads, engineering, operations and cross functional colleagues for both existing offerings as well as custom solutions. 

The Lead Pharmacy Systems Operations Specialist is responsible for overseeing and supporting the accurate, timely, and efficient adjudication of pharmacy claims across multiple platforms. This role ensures compliance with regulatory requirements, contractual obligations, and internal quality standards, while serving as a subject matter expert (SME) for claims processing workflows. The lead specialist will partner with internal teams, PBM vendors, pharmacies, and clients to troubleshoot claim issues, drive process improvements, and ensure members have seamless access to affordable medications.

Responsibilities:
 

Claims Adjudication Support

• Monitor and analyze inbound and outbound claims to ensure accurate adjudication according to program design and pricing requirements.

• Research, resolve, and document claim errors, rejects, and discrepancies within established service-level agreements (SLAs).

• Collaborate with PBM partners and pharmacies to address claim inquiries and resolve escalations efficiently.

Operational Excellence

• Develop, implement, and maintain standard operating procedures (SOPs) for adjudication processes.

• Partner with Engineering, Data, and Product teams to support system updates, configuration changes, and enhancements.

• Track and report operational metrics, trends, and recurring issues to management, recommending process improvements.

Quality Assurance & Compliance

• Support the development and implementation of quality assurance (QA) metrics for claims processing.

• Ensure compliance with CMS, HIPAA, and other regulatory guidelines in all claims adjudication activities.

• Perform audits to confirm accuracy of pricing and business rules.

Collaboration & Communication

• Act as a liaison between internal stakeholders (Pharmacy Services, Network Operations, Pricing Operations, Finance, Product, IT) and external partners to resolve claims-related issues.

• Provide training and guidance to internal teams on adjudication processes, workflows, and system capabilities.

• Support implementation of new client programs, program workflows, business rules and product enhancements by validating claims processing logic.

• Participate in industry working groups, regulatory forums, and knowledge bases.

Skills & Qualifications:

• 8+ years with a bachelor’s degree or equivalent, or equivalent practical experience as project or implementation manager, within pharmacy sector 

• Understanding of pharmacy claim adjudication, application of pricing rules, and associated claim data

• Proficiency in pharmacy claims systems, EDI transactions (NCPDP D.0 / F6, 835), and benefit design configuration.

• Proven track record of juggling multiple projects at a time while maintaining strong attention to detail

• Analytical problem solver with a strong work ethic who can work independently and collaboratively

• Strong SQL and Excel proficiency, or other data analysis/reporting tools preferred.

• Experience working with Power BI or Looker (preferred)

• Excellent communication and interpersonal skills, with the ability to build relationships and work effectively with cross-functional teams and leadership.

At GoodRx, pay ranges are determined based on work locations and may vary based on where the successful candidate is hired. The pay ranges below are shown as a guideline, and the successful candidate’s starting pay will be determined based on job-related skills, experience, qualifications, and other relevant business and organizational factors. These pay zones may be modified in the future. Please contact your recruiter for additional information.

San Francisco and Seattle Offices:

New York Office:

Santa Monica Office:

Other Office Locations:

GoodRx also offers additional compensation programs such as annual cash bonuses or commission, and annual equity grants for most positions as well as generous benefits. Our great benefits offerings include medical, dental, and vision insurance, 401(k) with a company match, an ESPP, unlimited vacation, 13 paid holidays, and 72 hours of sick leave. GoodRx also offers additional benefits like mental wellness and financial wellness programs, fertility benefits, generous parental leave, pet insurance, supplemental life insurance for you and your dependents, company-paid short-term and long-term disability, and more!

We’re committed to growing and empowering a more inclusive community within our company and industry. That’s why we hire and cultivate diverse teams of the best and brightest from all backgrounds, experiences, and perspectives. We believe that true innovation happens when everyone has a seat at the table and the tools, resources, and opportunities to excel.

With that said, research shows that women and other underrepresented groups apply only if they meet 100% of the criteria. GoodRx is committed to leveling the playing field, and we encourage women, people of color, those in the LGBTQ+ communities, individuals with disabilities, and Veterans to apply for positions even if they don’t necessarily check every box outlined in the job description. Please still get in touch - we’d love to connect and see if you could be good for the role!

GoodRx is committed to providing reasonable accommodations for candidates with disabilities during our recruiting process. If you need any assistance or accommodations due to a disability, please reach out to us at [email protected].

We prioritize candidate safety. Please be aware that all official communication will only be sent from @goodrx.com or [email protected] addresses.

GoodRx is America's healthcare marketplace. The company offers the most comprehensive and accurate resource for affordable prescription medications in the U.S., gathering pricing information from thousands of pharmacies coast to coast, as well as a tele-health marketplace for online doctor visits and lab tests. Since 2011, Americans with and without health insurance have saved $60 billion using GoodRx and million consumers visit goodrx.com each month to find discounts and information related to their healthcare. GoodRx is the #1 most downloaded medical app on the iOS and Android app stores. For more information, visit www.goodrx.com.