Apply advanced knowledge of policies, procedures, and benefit design to evaluate and resolve complex or sensitive cases, ensuring sound and compliant decision‑making
Serve as a subject matter expert by guiding research strategies, documentation standards, and the development of clear, accurate written responses
Review and validate case documentation and correspondence for accuracy, clarity, consistency, and regulatory or policy compliance
Assess cases to determine the need for escalation, reclassification, or additional review, and initiate appropriate actions to ensure timely resolution
Contribute to reporting, tracking, and documentation activities that support service‑level adherence, and performance monitoring
Identify opportunities for process, workflow, or quality improvements and support initiatives that enhance consistency, efficiency, and overall case handling effectiveness
Other duties as assigned
Requirements
High School diploma from an accredited school or equivalent GED
4 years of work experience in customer service, benefit plans, grievances or appeals
Must be eligible to work in the United States without the need for work visa or residency sponsorship
Additional Qualifications
Ability to be self-motivated and work with minimal supervision
Strong organizational, analytical, interpretive, problem solving and time management skills
Strong interpersonal communication skills, including conflict resolution and listening skills
Ability to work under strict timelines while managing priorities simultaneously
Ability to maximize interdepartmental and client resources
2 years of escalation resolution experience
Experience drafting professional correspondence
Prior healthcare and/or Government Programs (Medicare/Medicaid) experience
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures
Potential pay for this position ranges from $21.15 - $31.73 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Benefits
Health insuranceVision insurance
Additional Information
At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.
Job Posting Title
GPRT Research Specialist Lead Job Description
The Lead Research Specialist position is responsible for researching and resolving complex and escalated member issues while ensuring accurate, timely, and compliant outcomes. This position serves as a subject matter expert by providing guidance on research decisions, documentation, and written communications, and by supporting quality and consistency in case handling. This role also contributes to reporting, process improvements, and operational support to help meet service levels and performance expectations.
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