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Government Programs Operations Manager

Department: Government Programs Operations
Location: New York, NY

Location: Remote (For Non-Local) or Hybrid (Local to NYC area)

Position Summary:

The role of Government Programs Operations Manager is instrumental in ensuring the compliant and efficient administration of pharmacy benefits within the framework of ever-evolving Medicaid and Exchange regulatory landscapes. This individual will be required to have an in-depth understanding of regulations and how they govern operations within the respective markets in which we operate. Primary responsibilities will include the implementation and oversight of complex government program functions that adhere to regulatory guidelines. Utilizing research, analysis, testing, and validation to guarantee program effectiveness and compliance. Aligning program operations with overall business objectives while maintaining strict adherence to federal and state regulations. This combined approach ensures that the manager possesses the necessary expertise to implement effective processes, while fostering collaborative relationships with cross-functional areas in the organization.

Position Responsibilities:

  • Review contract and regulatory language to extract points requiring action or needing development work to maintain compliance

  • Maintain current knowledge of Medicaid and Exchange requirements to facilitate compliance of ongoing business operations

  • Monitor internal government program operations to identify gaps and/or resolve any identified operational discrepancies, including root cause analysis and implementation of necessary actions

  • Leverage in-depth understanding of the Medicaid and Exchange regulatory environments to support product strategy and service delivery

  • Collaborate with cross-functional teams to oversee the timely implementation of regulatory & sub-regulatory guidance

  • Support audits of government programs (government, client or internal)

  • Manage validation, submission, error handling, and change management for regulatory deliverables

  • Perform highly complex data analysis to ensure implemented solutions are functioning according to defined specifications

  • Help drive the implementation of internal process monitoring including the development of dashboards and reporting

  • Identifies opportunities for improvement and participates in the development of new solutions/capabilities in support of government program compliance and audit readiness

  • Document policies and procedures, reporting and project specifications, job aids and workflows within the department

  • Foster a culture high-performance through mentoring and collaboration.? Provide team members with constant and consistent performance feedback/direction.

  • Support with the assessment new business impact to understand scalability and staffing needs

Required Qualifications:

  • 4+ years of relevant PBM and/or Health Plan experience supporting Medicaid programs within the domain of pharmacy benefits

  • Thorough knowledge of Medicaid regulatory requirements and associated product and/or operational workflows within the domain of pharmacy benefits

  • Knowledge of relevant tools such as the Microsoft (MS) Office suite of product, MS Visio, JIRA, Confluence, etc.

  • Experience leveraging analytical tools such as SQL, R, or Python to analyze data

  • Familiarity with state pharmacy encounter submissions

  • Ability to balance multiple complex projects simultaneously

  • Extremely flexible, highly organized, and able to shift priorities easily

  • Attention to detail & commitment to delivering a high quality and timely work product

  • Excellent written and verbal communication skills

  • Proven experience within a similar role

  • Strong analytical, problem-solving, and critical thinking skills

  • Proficiency in requirement gathering and documentation techniques

  • Ability to collaborate effectively with cross-functional teams

  • Familiarity with the Agile software development methodology

Preferred Qualifications:

  • 6+ years of relevant PBM and/or Health Plan experience supporting Medicaid and Exchange programs within the domain of pharmacy benefits

  • Thorough knowledge of Medicaid and Exchange regulatory requirements and associated product and/or operational workflows within the domain of pharmacy benefits

  • Knowledge of HEDIS and Risk-Adjustment/RxHCC methodologies

  • Familiarity with state pharmacy encounter and healthcare exchange submissions

Base Salary: $95,000 - $105,000

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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