Senior Manager, Government Programs Operations - Medicare

Location: Hybrid (Local to NYC area)

Position Summary:

The Senior Manager, Government Programs Operations - Medicare is responsible for ensuring accurate adjudication of Medicare Part D prescription drug claims while maintaining compliance with CMS regulations. The ideal candidate will have extensive knowledge of Medicare Part D claims processing rules, regulatory changes to claim adjudication requirements, and industry best practice standards.

Position Responsibilities:

Claims Adjudication and analysis:

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  Review, analyze, and resolve Medicare Part D claims to ensure compliance with CMS guidelines

  
  

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  Investigate claim rejections, overrides, and disputes to identify root causes and coordinate corrective actions

  
  

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  Monitor claims processing systems to detect anomalies, inaccuracies, or trends requiring intervention

  
  

Regulatory Compliance & Quality Assurance:

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  Ensure compliance with CMS regulations and internal policies related to Medicare Part D claims processing

  
  

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  Provide subject matter expertise for regulatory audits, client pre/post delegation audits, and internal quality reviews, as required

  
  

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  Stay up to date on regulatory changes impacting Medicare Part D claim processing and communicate updates to stakeholders to ensure all internal systems and processes comply with current requirements

  
  

Process Improvement and System Support:

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  Collaborate with IT and operations teams to optimize claims adjudication workflows and system configurations

  
  

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  Identify and recommend process enhancements to improve efficiency and accuracy in claims processing

  
  

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  Work with Medicare clients, pharmacies, and internal teams to resolve escalated claim issues

  
  

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  Develop and maintain documentation related to Medicare Part D claims adjudication policies and procedures

  
  

Leadership:

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  Manage a team of analysts to achieve goals, fostering a positive and productive work environment.

  
  

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  Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

  
  

Minimum Qualifications:

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  6+ years of experience in Medicare Part D claims processing within a PBM

  
  

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  Extensive knowledge of CMS regulations, Medicare Part D benefit designs, and claims adjudication processes

  
  

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  Ability to operationally interpret and apply Medicare Part D regulations and guidance effectively

  
  

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  Strong analytical and problem-solving skills, with attention to detail

  
  

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  PDE (Prescription Drug Event) reporting and reconciliation subject matter expertise preferred

  
  

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  Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables

  
  

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  Experience successfully managing a team of direct reports

  
  

Base Salary: $120,000 - $135,000

Visa Sponsorship: Capital Rx does not provide sponsorship to any candidates. This includes, but is not limited to those that require H1-B, TN, OPT, etc. Candidates must have authorization to work in the US at the time of application and throughout employment.

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation's electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI, the company's cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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