Note: The job is a remote job and is open to candidates in USA. Capital Rx is an enterprise health technology company focused on delivering comprehensive pharmacy benefit management solutions. The Government Programs Operations Manager is responsible for overseeing the implementation and compliance of Medicare, Medicaid, and Exchange programs while leading a team to identify and maintain operational efficiencies.
Responsibilities
- Interpret and operationalize CMS/state regulatory and sub-regulatory guidance in collaboration with Compliance and internal SMEs
- Oversee timely implementation of regulatory changes, coordinating cross-functional workplans across impacted departments
- Monitor internal operations for government programs, identify and resolve errors through root cause analysis, and implement corrective actions
- Support claims correction activities related to retro-eligibility and coordination of benefits (COB), while placing focus on the accurate reprocessing of claims
- Support internal, client, and government audits by ensuring data accuracy, process transparency, and documentation completeness
- Drive team to maintain comprehensive documentation including policies, procedures, job aids, workflows, and reporting specifications
- Lead the development of automated tools and scalable solutions to improve operational efficiency and data accuracy
- Analyze complex encounter and PDE data using internal and external sources to identify trends, outliers, and improvement opportunities
- Define and document business and reporting requirements to support system enhancements and process improvements
- Track performance metrics for encounter and PDE submissions, ensuring alignment with client and regulatory expectations
- Promote subject matter expertise within the team by encouraging proactive process reviews and knowledge sharing for purpose of establishing continuity within the team and its processes
- Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance
Skills
- 5+ years of healthcare data experience
- 5+ years of relevant PBM and/or Health Plan experience supporting Medicare Part D, Medicaid, or Exchange plans
- 5+ years of experience working with SQL, R, or Python
- Experience working with cross-functional teams
- Ability to balance multiple complex projects simultaneously
- Extremely flexible, highly organized, and able to shift priorities easily
- Attention to detail & commitment to delivering high quality work product
- Flexibility to respond to a range of different work situations
- Excellent written and verbal communication skills
- Ability to foster a culture of collaboration and high performing team
Company Overview
Capital Rx is now Judi Health! Navigate to our new page here: https://www.linkedin.com/company/judi-health It was founded in 2017, and is headquartered in New York, New York, USA, with a workforce of 501-1000 employees. Its website is https://www.judi.health.