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.

Position Summary:

Capital Rx is seeking a self-driven payment operations manager to support the creation, configuration, and management of provider and member payments for JUDI Health, Capital Rx’s enterprise health platform.

In year one, this individual will build the payment operations team, help guide the build-out of infrastructure to support industry-standard Medical Payments options and integration with our third party payments vendor. This individual will also be responsible for maintaining the operational payments process, member, and provider payment inquiry management, recoupment and adjustment flows, and adhering to prompt-pay timelines.

In year two, this individual will be responsible for managing and servicing new and existing clients of JUDI’s Medical Claims Adjudication platform. This individual will be expected to maintain an in-depth understanding of the evolving capabilities of JUDI and our medical network support and client base. Exceptional communication skills and attention to detail are critical for communicating with internal and external stakeholders to build holistic support for payments processing.

Position Responsibilities:

• Configure, test and validate Medical Payments workflows

• The TPA Payment Ops manager will be responsible for direct reports, and developing workflows, policies, and procedures related to the claims payment process.

• Build and maintain trusting relationships with clients through superior customer service. Provide oversight of future network integrations and client implementation.

• Accountable for accurate and timely transition of new clients into the payments platform.

• Lead communications throughout the implementation process, including detailed and strategic guidance for payments infrastructure, processing, reporting, inquiry management, and complex claim situations/requests.

• Proactively identify execution risks and mitigation strategies.

• Provide ongoing stakeholder support to troubleshooting inquiries.

• Understand and manage requests for new features in alignment with the product roadmap.

• Partner with product managers and directors operating in an agile framework to conceptualize and break down functional and non-functional requirements needed to adhere to all contractual and federal payments regulations.

• Identify and drive efficiencies to automate payments flows and reduce risk.

• Certain times of year may require meeting participation, service support or other requirements outside of standard business hours, including weekends.

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

Minimum Qualifications:

• Experience managing a team of direct reports

• 5+ years of work experience at a medical payments vendor, health plan, or TPA

• Well-versed in 837 and 835 EDI files

• Well-versed in payment regulations in the medical space including NACHA standards and CAQH CORE rules

• Well-versed in impact of claims processing and adjudication in regards to payments

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

• Exceptional project / time management, prioritization, and organizational skills to ensure customer satisfaction

• Ability to shift between competing priorities and meet organizational goals

• Proficient in Microsoft office Suite and willing to adapt to software such as Jira, Miro, Confluence, Github, and AWS Redshift

• Excellent verbal, written, interpersonal and presentation skills

• Ability to work effectively with virtual teams

Preferred Qualifications:

• Medicare/Medicaid experience preferred

• Experience with ECHO payment platform preferred

• Bachelors degree strongly preferred

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Base Salary: $115,000 - 130,000

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.