Claims Consultant

Location: Cadillac, Michigan, United States. The role is listed as remote, but candidates should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

Company

hirify.global provides insurance and benefits services, including pharmacy benefit support for self-funded organizations.

What you will do

• Review, investigate, and resolve pharmacy benefit claim issues and member inquiries.
• Analyze claim adjudication outcomes, identify processing errors, and determine corrective actions.
• Coordinate with pharmacies, PBMs, TPAs, carriers, brokers, plan sponsors, and internal teams on complex claims.
• Research eligibility, benefit designs, prior authorization requirements, formularies, and plan provisions.
• Audit and reconcile pharmacy claims data, monitor payment accuracy, and maintain investigation documentation.
• Support client implementations, benefit plan changes, member education, and service delivery.

Requirements

• Bachelor’s degree in business, healthcare administration, finance, insurance, public health, or a related field preferred; equivalent experience may be considered.
• At least 3 years of experience in health insurance, pharmacy benefits, claims administration, healthcare operations, or a related industry.
• Understanding of healthcare claims processing, pharmacy benefit administration, prescription drug benefits, specialty pharmacy programs, and utilization management.
• Strong analytical, problem-solving, communication, customer service, organizational, and documentation skills.
• Ability to independently prioritize, investigate, resolve, escalate, and follow up on complex claims issues.
• Comfort with an on-site presence in Cadillac, Michigan, is required to support collaboration and cross-functional partnership.

Nice to have

• Experience with self-funded health plans, PBMs, TPAs, pharmacy benefit programs, claims adjudication systems, reporting platforms, or healthcare data.
• Bilingual English/Spanish communication skills.
• Proficiency in Microsoft Office Suite, particularly Excel.

Culture & Benefits

• Medical, dental, vision, life, and disability insurance.
• Paid time off, holidays, sick time, maternity and paternity leave, including adoption leave.
• 401(k) with immediate vesting, HSA and FSA options, commuter benefits, and employee discounts.
• Fertility benefits, wellness resources, an Employee Assistance Program, and Calm app access.
• Legal plan options and pet insurance.