About Judi Health

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), consolidating all claim administration-related workflows in one scalable, secure platform.

Position Summary

Position Responsibilities

• Support the team lead with day-to-day operational tasks related to claims processing, including testing, troubleshooting, documentation and Encounter Data submissions.
• Oversee error handling and change management for Encounters, ensuring compliance with CMS, State, and client requirements.
• Conduct root cause analysis and implement corrective actions for operational issues, collaborating across departments to drive resolution.
• Monitor claims processing and adjudication trends, identifying systemic issues and opportunities for process improvement.
• Manage complex claims corrections, including retro-eligibility changes, COB adjustments, and other regulatory-driven updates.
• Serve as a subject matter expert (SME) for Medicare, Medicaid, and Exchange operations, supporting internal teams and external stakeholders.
• Support development and testing of operational processes, tools, and project deliverables.
• Establish and promote best practices for government programs operations, ensuring scalability and compliance.
• Support product strategy and service delivery by leveraging deep knowledge of Medicare & Medicaid regulatory environments.
• Stay current on CMS/State regulatory guidance updates, translating changes into actionable operational strategies.
• Mentor and guide analysts, fostering professional development and knowledge sharing.
• Maintain current knowledge of Medicare, Medicaid, and Exchange requirements to facilitate compliance of ongoing business operations.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications

• 2+ years of experience in PBM or Health Plan operations, focusing on Medicare Part D and/or Medicaid/Exchange programs.
• Proven expertise in Exchange, Medicaid, and Medicare regulatory requirements and operational workflows, including PDE, and Encounter/Edge Data.
• MS Excel skills (pivot tables, complex formulas, VLOOKUP’s).
• Proficient in collaborating across functional teams and managing competing priorities in a dynamic and fast-paced environment.
• Analytical and problem-solving skills with a track record of driving operational improvements.
• Excellent communication and stakeholder management skills, including experience presenting to leadership and clients.
• Foundational understanding of Federal/State compliance requirements.
• Highly organized, detail-oriented, and committed to high-quality work.