Location: Remote (For Non-Local) or Hybrid (Local to NYC, Denver, or Charlotte) 

Position Summary:

The Account Manager, PBM is responsible for timely and accurate management and execution of all client benefit requests, including benefit changes, eligibility changes, and new implementations. Support implementation of new plans, pricing, and networks, consistent with strategic or administrative intent.

Position Responsibilities:

• Partner with clinical account manager (CAM) and account executive (AE) to manage clients through the entire lifecycle from implementation through go-live and renewal on a designated book of business  

• Support implementation as a critical member of the client management teams with all day-to-day client requirements 

• Responsible for timely and accurate management and execution of all client benefit requests, including benefit changes, eligibility changes, override requests, demos and new implementations 

• Analyze incoming client requests and work with internal and external teams to complete required plan documentation 

• Support implementation of new plans, pricing, and networks, consistent with strategic or administrative intent 

• Lead pre- and post-implementation quality assurance and testing to validate coding accuracy 

• Lead claim reviews to proactively identify discrepancies or inaccuracies and develop solutions to address 

• Travel requirements not to exceed 25% 

• Handle and resolve sponsor and member issues, escalating as needed 

• Research and respond to claims processing and system configuration inquiries 

• Coordinate integration of other data inputs into client management processes 

• Collaborate cross functionally to support general client operations, as required 

• Responsible for relationship management and contribution to successful NPS and Account Management Survey results, along with retention support 

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

Qualifications:

• Undergraduate bachelor’s degree, with record of strong academic performance 

• 5+ years of proven experience in PBM / health plan, benefits consulting, healthcare 

• Track record of building trusting internal and external relationships 

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

• Experience working with structured and unstructured data 

• Proficient in Microsoft Office, SQL a bonus 

• Ability to balance multiple complex projects simultaneously 

• Exceptional written and verbal communication skills 

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

• Attention to detail & commitment to delivering high quality work product 

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. 

Position Overview:

The Account Executive/Strategic Account Executive - PBA Services is responsible for managing the planning, execution, growth & retention and client satisfaction of assigned clients in the Pharmacy Benefit Administration (PBA) market segment including Health Plans, Third Party Administrators (TPAs), and other Platform services. Additionally, this position will lead and collaborate through the broader Account Management team and with internal Capital Rx teams/departments as the client voice and advocate to ensure ongoing client satisfaction and to achieve client priorities and contractual obligations.

This position acts as the quarterback and leader of the broader Account Management team who are aligned in support of our clients. This position reports to the Senior Account Executive/Senior Director, PBA Client Services.

Position Responsibilities:

• Work closely with some of our biggest Texas-based clients and manage the complexities of working within a highly-regulated market of the TDI (Texas Department of Insurance)

• Provide oversight and direction to the broader Account Management team with a focus on member and client satisfaction, trend management, client growth & retention, and regulatory compliance to meet client specific objectives, client priorities and service model deliverables

• Lead and develop the client relationship strategy and the strategic business planning process across the clients in your portfolio while incorporating other internal staff where and when needed to build and foster relationships with influencers and decision makers.

• Maintain thorough knowledge and tracking of contractual obligations on assigned book of business, including financials, performance guarantees, terms, and reporting/compliance

• Manage and facilitate the Account renewal and contracting process with a focus on client retention and the client financial/PNL management

• Serve as the relationship lead on assigned book of business, incorporating other internal staff where and when needed to the relationship; build and foster relationships with influencers and decision makers at the client

• Anticipates customer needs and proactively identifies new opportunities within assigned accounts.

• Develop and maintain comprehensive knowledge of our business, including products and services to field questions from the client side and to answer timely & accurately

• Collaborate with internal teams to customize offerings and solutions, aligning with Health Plan/TPA Account needs and market demands - assemble internal resources to overcomes challenges.

• Analyze and interpret current pharmacy and healthcare trends, competitor activities, and industry regulations to inform strategic decisions, provide proactive recommendations for plan management and enhance the company's positioning within the PBA Services segment

• Lead, coach and support the Account Team on the effective positioning of the Capital Rx value proposition, our suite of Capital Rx Products and Solutions and JUDI capabilities available to our PBA clients

• Partner with our Business Development, Underwriting Teams & Senior Account Executives to support our PBA Account level growth and retention efforts by providing with Capital Rx sales support and market differentiator positioning, including RFP support, Broker/Consultant engagement and Best & Final support for prospective, existing and new and client business development needs

• Provide ongoing direction, coordination and coaching to the broader Account Team to align the Account Team understanding of the assigned client(s) business lines, strategies, key stakeholders & decision makers and priorities

• Serve as the content expert for Health Plan/TPA clients & opportunities

• Identify and help contribute to process improvement efforts

• Be accountable & own the client end-to end, inclusive of service model deliverables, contractual negotiations, client escalations and PNL management.

• All employees are responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications:

• Bachelor’s or advanced degree in health administration, business, or relevant professional experience. Bachelor of Pharmacy (B.S. Pharmacy) or Doctor of Pharmacy (PharmD) degree from an accredited institution is a plus

• Relevant professional experience for at least five (5) years in pharmacy – working within a health plan, managed care, or pharmacy benefits management (PBM) focused on Health Plans and Payer Commercial (Insured, Self-Funded, Exchange) and Government Program (Medicare & Medicaid) business lines. Health plan industry experience highly preferred

• Market and operational knowledge of Medicare Part D, Medicaid and Health Exchange pharmacy is required along with experience in supporting highly regulated business lines

• Track record of building trust in internal and external relationships

• Solution-focused problem solving and client positioning skills

• Exceptional written and verbal communication skills

• Ability to work with and influence peers in a team effort; leading cross-functional initiatives, meeting deadlines, and executing on deliverables while building strong internal relationships

• A decisive individual with sound technical skills, analytical ability, good judgement, and strong operational focus and detail-oriented perspective

• Flexible, highly organized, and able to shift priorities easily and work independently to meet deadlines

• Ability to effectively work with peers in a team effort

• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and large data sets and other industry software programs

• Ability to travel and present to small and large groups; travel is estimated to be up to 25% and be variable by season and business cycle

Preferred Qualifications:

• Experience working with clients who are subject to TDI (Texas Department of Insurance) rules and regulations

#LI-BC1

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

About Capital Rx:

Capital Rx is a full-service pharmacy benefit manager (PBM) overseeing prescription benefit plans on behalf of employers, unions, and government entities in the commercial space and provides Pharmacy Benefit Administration (PBA) services to Health Plans and TPAs.  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 Overview:

The Account Executive/Strategic Account Executive - PBA Services is responsible for managing the planning, execution, growth & retention and client satisfaction of assigned clients in the Pharmacy Benefit Administration (PBA) market segment including Health Plans with multiple lines of businesses, Third Party Administrators (TPAs), commercial employer groups, and other Platform services.  Additionally, this position will lead and collaborate through the broader Account Management team and with internal Capital Rx teams/departments as the client voice and advocate to ensure ongoing client satisfaction, retention, and to achieve client priorities and contractual obligations.

This position acts as the quarterback and leader of the broader Account Management team who are aligned in support of our clients. This position reports to the Senior Director, PBA Client Services.

Position Responsibilities:

• Provide oversight and direction to the broader Account Management team with a focus on client satisfaction, trend management, client growth & retention, and regulatory compliance to meet client specific objectives, client priorities and service model deliverables
• Lead and develop the client relationship strategy and the strategic business planning process across the clients in your portfolio while incorporating other internal staff where and when needed to build and foster relationships with influencers and decision makers
• Maintain thorough knowledge and tracking of contractual obligations on assigned book of business, including financials, performance guarantees, terms, and reporting/compliance
• Manage and facilitate the Account renewal and contracting process with a focus on client retention and the client financial/PNL management
• Serve as the relationship lead on assigned book of business, incorporating other internal staff where and when needed to the relationship; build and foster relationships with influencers and decision makers at the client
• Anticipates customer needs and proactively identifies new opportunities within assigned accounts
• Develop and maintain comprehensive knowledge of our business, including products and services to field questions from the client side and to answer timely & accurately
• Collaborate with internal teams to customize offerings and solutions, aligning with Health Plan/TPA Account needs and market demands - assemble internal resources to overcomes challenges 
• Analyze and interpret current pharmacy and healthcare trends, competitor activities, and industry regulations to inform strategic decisions, provide proactive recommendations for plan management and enhance the company's positioning within the PBA Services segment
• Lead, coach and support the Account Team on the effective positioning of the Capital Rx value proposition, our suite of Capital Rx Products and Solutions and JUDI capabilities available to our PBA clients
• Partner with our Business Development & Underwriting Teams to support our PBA Account level growth and retention efforts by providing Capital Rx sales support and market differentiator positioning, including RFP support, Broker/Consultant engagement and Best & Final support for prospective, existing and new and client business development needs
• Provide ongoing direction, coordination and coaching to the broader Account Team to align the Account Team understanding of the assigned client(s) business lines, strategies, key stakeholders & decision makers and priorities
• Serve as the content expert for Health Plan/TPA clients & opportunities
• Identify and help contribute to process improvement efforts
• Be accountable & own the client end-to end, inclusive of service model deliverables, contractual negotiations, client escalations and PNL management.
• All employees are responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications:

• Bachelor’s or advanced degree in health administration, business, or relevant professional experience. Bachelor of Pharmacy (B.S. Pharmacy) or Doctor of Pharmacy (PharmD) degree from an accredited institution is a plus
• Relevant professional experience for at least five (5) years in pharmacy – working within a health plan, managed care, or pharmacy benefits management (PBM) focused on Health Plans and Payer Commercial (Insured, Self-Funded, Exchange) and Government Program (Medicare & Medicaid) business lines.  Health plan industry experience preferred
• Market and operational knowledge of Medicare Part D, Medicaid and Health Exchange pharmacy is a plus along with experience in supporting highly regulated business lines
• Track record of building trust in internal and external relationships
• Solution-focused problem solving and client positioning skills
• Exceptional written and verbal communication skills
• Ability to work with and influence peers in a team effort; leading cross-functional initiatives, meeting deadlines, and executing on deliverables while building strong internal relationships
• A decisive individual with sound leadership and technical skills, analytical ability, good judgement, and strong detail-oriented perspective
• Flexible, highly organized, and able to shift priorities easily and work independently to meet deadlines
• Ability to effectively work with peers in a team effort
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and large data sets and other industry software programs
• Ability to travel and present to small and large groups; travel is estimated to be up to 25% and be variable by season and business cycle.

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

Position Responsibilities:

• Provide oversight of commercial clients within the health system, employer, labor/union and public verticals for large/jumbo accounts (approximately >15,000+ lives, subject to fluctuate due to the needs of the business)
• Serve as the relationship liaison on assigned book of business, incorporating internal support where and when needed to the foster relationship with influencers and decision makers at the plan
• Develop relationship strategy plans, with support of clinical account manager and operations manager
• Support member and client satisfaction execution and net promoter score goals
• Provide deep and approachable trend management recommendations with support of reporting 
• Maintain thorough knowledge of contractual obligations assigned book of business, including financials, performance guarantees, terms, and regulatory/compliance
• Lead client renewal process, including contract management 
• Lead ownership of performance guarantee reporting and maintenance 
• Lead regulatory and compliance components 
• Interpret current pharmacy and healthcare trends, and meet with clients to provide proactive recommendations for plan management; find ways of adding value to the client curating offerings tailored to the client’s specific needs
• Identify and contribute to process improvement efforts across Capital Rx
• Assemble internal resources to overcomes challenges
• Anticipates customer needs and proactively identifies new opportunities within assigned accounts
• Comprehensive knowledge of our business, including products and services. Strong ability to field questions from the client side, answer them and answer them correctly
• Review and advise on JUDI product roadmap to ensure current priorities and milestones will meet the client expectation
• Other duties as assigned
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Required Qualifications:

• 5+ years’ experience in the healthcare industry and/or pharmacy benefits experience
• Bachelor’s or advanced degree in health administration, business, or relevant professional experience
• PharmD preferred, but not required
• Exceptional business acumen skills 
• Strong clinical knowledge and expertise 
• Strong data analysis and presentation skills
• Financial and statistical reporting knowledge and experience
• Project management experience preferred
• Ability to exercise considerable judgement, maintain confidentiality, and act in a diplomatic manner
• Travel is estimated to not exceed 25% in the busiest times of year
• Progressive staff management experience
• An educator who is trustworthy and willing to share information and serve as a mentor
• Ability to independently identify, research and resolve issues
• A person who can relate to people at all levels of an organization and possesses excellent communication skills
• An excellent facilitator who is experienced in resolving conflicts between different parties to a dispute
• A decisive individual who possesses a strategic focus as well as an operational, implementation, and detail-oriented perspective
• A strategic planner with sound technical skills, analytical ability, good judgement, and strong operational focus
• Ability to work with peers in a team effort
• Demonstrated ability to manage multiple priorities and deadlines
• Ability to work extended hours, weekends, and holidays pursuant with industry demands
• Proficient in Microsoft Office and industry related software programs

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

Position Responsibilities:

• Provide oversight of commercial clients within the health system, employer, labor/union and public verticals for large/jumbo accounts (approximately >15,000+ lives, subject to fluctuate due to the needs of the business)
• Serve as the relationship liaison on assigned book of business, incorporating internal support where and when needed to the foster relationship with influencers and decision makers at the plan
• Develop relationship strategy plans, with support of clinical account manager and account manager
• Lead strategic reviews (e.g. QBRs), prioritize initiatives and maintain momentum across sales and implementation cycles.
• Support member and client satisfaction execution and net promoter score goals
• Provide deep and approachable trend management recommendations with support of reporting 
• Maintain thorough knowledge of contractual obligations assigned book of business, including financials, performance guarantees, terms, and regulatory/compliance
• Lead client renewal process, including contract management 
• Lead ownership of performance guarantee reporting and maintenance 
• Lead regulatory and compliance components 
• Interpret current pharmacy and healthcare trends, and meet with clients to provide proactive recommendations for plan management; find ways of adding value to the client curating offerings tailored to the client’s specific needs
• Identify and contribute to process improvement efforts across Capital Rx
• Assemble internal resources to overcomes challenges
• Anticipates customer needs and proactively identifies new opportunities within assigned accounts
• Comprehensive knowledge of our business, including products and services. Strong ability to field questions from the client side, answer them and answer them correctly
• Review and advise on JUDI product roadmap to ensure current priorities and milestones will meet the client expectation
• Other duties as assigned
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Required Qualifications:

• 5+ years’ experience in the healthcare industry and/or pharmacy benefits experience
• Demonstrated experience supporting integrated delivery networks (IDNs), hospital systems, or academic medical centers
• Strong ability to navigate and balance plan sponsor goals (e.g. cost control, benefit design, member experience) with health-system pharmacy objectives (e.g. revenue protection, access, utilization management)
• Experience facilitating consensus among stakeholders with competing incentives, using data, clinical rationale, and contract terms to drive alignment
• Working knowledge of 340B program mechanics
• Understanding of healthcare regulatory considerations impacting health systms and PBM oversight.
• Bachelor’s or advanced degree in health administration, business, or relevant professional experience
• Strong data analysis and presentation skills
• Financial and statistical reporting knowledge and experience
• Ability to exercise considerable judgement, maintain confidentiality, and act in a diplomatic manner
• Travel is estimated to not exceed 25% in the busiest times of year
• Progressive staff management experience
• An educator who is trustworthy and willing to share information and serve as a mentor
• Ability to independently identify, research and resolve issues
• A person who can relate to people at all levels of an organization and possesses excellent communication skills
• An excellent facilitator who is experienced in resolving conflicts between different parties to a dispute
• A decisive individual who possesses a strategic focus as well as an operational, implementation, and detail-oriented perspective
• A strategic planner with sound technical skills, analytical ability, good judgement, and strong operational focus
• A well-organized and self-directed individual who can work with minimal amount of supervision
• Ability to work extended hours, weekends, and holidays pursuant with industry demands
• Proficient in Microsoft Office and industry related software programs

Preferred Qualifications:

• PharmD preferred, but not required
• Project management experience preferred

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

Position Summary:

The Government Programs Operations Specialist is a hands-on position responsible for coordinating the day-to-day operations and activities of the Government Programs Operations team. This position provides the candidate a career growth opportunity while learning about Medicare Part D, Medicaid and Exchange business. 

Position Responsibilities:

• Manage the Government Programs Operations team shared Outlook mailbox, including but not limited to timely, accurate and complete responses, and ensuring timeframes for deliverables.
• Lead and execute pharmacy outreach initiatives related to CMS disputes, ensuring compliance with regulatory requirements and internal Government Operations procedures while applying judgment in communication strategy and issue resolution
• Serve as a key contributor in the validation of system enhancements, including evaluating output data, identifying discrepancies, and providing recommendations to improve system performance and data integrity. 
• Design, maintain, and continuously improve structured documentation frameworks, including job aids, policies and procedures (P&Ps), standard operating procedures (SOPs), and training materials to support operational consistency and scalability. 
• Develop and optimize internal workflows and job aids, driving process standardization and identifying efficiency opportunities across Government Programs Operations. 
• Oversee daily PDE reconciliation activities, analyzing trends, identifying variances, and proactively addressing discrepancies to ensure data accuracy and compliance. 
• Manage and resolve escalations arising from claims monitoring activities by applying critical thinking, root cause analysis, and cross-functional collaboration. 
• Support strategic Government Programs Operations initiatives, contributing insights, process improvements, and subject matter expertise as assigned. 
• Plan, coordinate, and facilitate cross-functional meetings to drive alignment, resolve issues, and advance operational objectives. 
• Collaborate closely with Government Programs Operations team members and business partners to address operational needs, improve processes, and support broader organizational goals. 

Required Qualifications: 

• 3+ years of experience in an equivalent role 
• High school diploma required 
• Experience with Medicare Part D and/or Pharmacy Technician experience preferred 
• Organizational skills and a very keen eye for detail and accuracy. 
• Experience working in high-growth, startup environments - an advantage. 
• A positive and upbeat attitude, and excellent interpersonal communication skills.
• A commitment to delivering a high level of customer service, both internally and externally. 
• Flexibility to respond to a range of different work situations. 
• An ability to work under pressure and juggle multiple priorities at any given time. 
• An ability to work well independently and be an effective collaborator within and across teams. 

Location: Remote or Hybrid (Local to NYC or Denver area)

As an Account Manager focused on PBA and Medicare, you'll be at the forefront of delivering seamless client experiences by managing benefit changes, implementing new plans, and ensuring pricing accuracy—all while driving impactful solutions that directly shape business success. You’ll lead key quality assurance initiatives, proactively identify claim discrepancies, and collaborate across teams to streamline processes, making a tangible impact on client satisfaction and operational efficiency. Your expertise will be essential in shaping client strategies, resolving complex issues, and upholding the values that keep Capital Rx ahead of the competition.

Position Responsibilities:

• Partner with clinical account manager (CAM) and account executive (AE) to manage clients through the entire lifecycle from implementation through go-live and renewal on a designated book of business
• Support implementation as a critical member of the client management teams with all day-to-day client requirements
• Responsible for timely and accurate management and execution of all client benefit requests, including benefit changes, eligibility changes, override requests, demos and new implementations
• Analyze incoming client requests and work with internal and external teams to complete required plan documentation
• Support implementation of new plans, pricing, and networks, consistent with strategic or administrative intent
• Lead pre- and post-implementation quality assurance and testing to validate coding accuracy
• Lead claim reviews to proactively identify discrepancies or inaccuracies and develop solutions to address
• Travel requirements not to exceed 25%
• Handle and resolve sponsor and member issues, escalating as needed
• Research and respond to claims processing and system configuration inquiries
• Coordinate integration of other data inputs into client management processes
• Collaborate cross functionally to support general client operations, as required
• Responsible for relationship management and contribution to successful NPS and Account Management Survey results, along with retention support
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Qualifications / Profile:

• Undergraduate bachelor’s degree, with record of strong academic performance
• 5+ years of proven experience in PBM / health plan, benefits consulting, healthcare
• Track record of building trusting internal and external relationships
• Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables
• Experience working with structured and unstructured data
• Proficient in Microsoft Office, SQL a bonus
• Ability to balance multiple complex projects simultaneously
• Exceptional written and verbal communication skills
• Extremely flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product

Position Summary

The Director of Risk Management serves as the strategic leader for client audit oversight and contract‑related risk across Client Services. This role builds and governs the frameworks that standardize audit execution, elevate documentation quality, and strengthen performance guarantee (PG) risk management. By partnering closely with Legal, Compliance, Finance, and Client Services leadership, the Director enhances organizational visibility into risk, accelerates workflow efficiency, and ensures the company is consistently prepared to meet regulatory and client expectations.

Position Responsibilities:

• Lead strategy and governance for regulatory and client audit programs.
• Establish standardized intake, documentation, and response processes for all audits.
• Ensure consistency and quality of documentation and narrative language across audit submissions.
• Evaluate current contract‑ and PG‑related processes, identify risks or gaps, and recommend improvements to strengthen oversight.
• Develop governance practices to support risk monitoring, escalation, and cross-functional communication.
• Partner with Legal, Compliance, and Finance to manage risk frameworks and coordinate responses.
• Lead and develop audit and PG support staff.
• Oversee development of reporting and dashboards that highlight trends, risks, and performance indicators.

Required Qualifications:

• Bachelor’s degree required; advanced degree preferred.
• 7+ years of experience in regulatory audits, compliance, or risk management in healthcare or related fields.
• Experience leading cross-functional audit programs or oversight functions.
• Strong writing, documentation, and narrative development skills.
• Ability to influence and collaborate across senior stakeholders.

Position Summary

The Manager of Client Experience Resolution & Optimization (CERO) leads the intake, triage, and resolution process for client-impacting issues within Client Services. This role establishes governance for intake workflows, ensures issues are accurately validated and routed, and drives consistency in how Client Services manages and resolves operational challenges. The Manager partners across the organization to streamline processes, reduce manual work, and improve end-to-end client experience, while providing coaching for the CERO Analyst.

Position Responsibilities:

• Build and manage a standardized intake and routing process for Client Services issues.
• Govern issue of triage, prioritization, and cross-functional coordination.
• Serve as the primary point of contact for inquiries related to intake, validation, and routing.
• Develop and maintain SOPs, workflows, and documentation supporting Client Services operations.
• Establish and monitor high‑level performance indicators (e.g., intake volumes, turnaround times, quality measures) in partnership with internal analytics teams.
• Lead continuous improvement initiatives aimed at simplifying workflows and reducing recurring issues.
• Partner with functional teams to identify process gaps and support implementation of improvements.
• Coach, mentor, and support ongoing development of the CERO Analyst.

Required Qualifications:

• Bachelor’s degree is required
• 5+ years of experience in client services, operations, or workflow/process management.
• Demonstrated success in establishing governance structures or managing intake of workflows.
• Strong collaboration, communication, and organizational skills.
• Ability to manage complexity and problem-solve in a fast-paced environment.

Position Summary: 

The Senior Analyst, Government Programs Operations - Analysis & Efficiencies will play a pivotal role in supporting the operational success of Medicare, Medicaid, and the Exchange programs. This analyst develops data-driven solutions that enhance efficiency and reduce manual efforts. Under the guidance of the Operations Manager, this analyst utilizes complex datasets to identify actionable insights that inform strategic decisions and drive ongoing improvement. The analyst’s responsibilities encompass delivering recurring and ad-hoc reports, designing and leading the implementation of BI dashboards, and creating standardized code templates to automate deliverables. Additionally, the analyst contributes to process optimization by designing scalable, automated solutions that streamline workflows and minimize manual intervention. Collaboration with cross-functional teams, including compliance, product, sales, marketing, underwriting, implementation, client services, and clinical operations, is crucial to ensure that analytical tools and operational capabilities align with both regulatory requirements and business objectives.

Position Responsibilities: 

• Analyze complex datasets to identify trends, outliers, and opportunities for operational improvement across Medicare, Medicaid, and Exchange programs

• Develop and maintain recurring and ad-hoc reports, dashboards, and analytical tools to support data-driven decision-making

• Create and maintain a repository of standardized code templates to streamline report generation and automate routine tasks

• Ensure analytical outputs align with regulatory requirements and business objectives by interpreting CMS and state guidance in partnership with internal subject matter experts.

• Support the development of scalable processes that enhance efficiency, accuracy, and responsiveness across government program operations

• Design and implement automated solutions to reduce manual effort and improve process scalability and accuracy

• Implements and uses analytical software to support the department in achieving goals as defined by executive leadership

• Facilitate requirements gathering sessions to understand business needs and translate them into actionable analytical deliverables

• Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery, and cost savings regulations are met

• Presents and communicates complex analytical findings in a clear and concise manner

• Participates in user acceptance, and quality assurance testing of new application features and team deliverables

• Supports root-cause-analysis and reporting of encounter data issues/errors by partnering with key stakeholders – Will also provide operationally support

• Prepares high-level user documentation and training materials as needed

• Work with internal and external clients to research, develop, and document new standards to enhance reporting capabilities

• Collaborate with cross-functional teams—including compliance, product, sales, marketing, underwriting, implementation, client services, and clinical operations—to refine and enhance operational capabilities

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

Required Qualifications:

• 4+ years of healthcare data experience

• 4+ years of experience working with SQL, R, or Python

• 4+ years of experience working with business intelligence tools

• Experience performing analyses on large sets of data

• Knowledge of data management, statistics, modeling concepts

• Experience working with cross-functional teams

• Experience with Power BI or other data visualization tools

• 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

• Bachelor's degree in Business Administration, Data Analytics or 4+ years of relevant experience

Preferred Qualifications:

• 4+ years of proven experience in government programs

• 3+ years of experience working with pharmacy data

• Experience with Medicare(Part D), Medicaid, and/or Marketplace Pharmacy Data/Processes

Location: Hybrid (Local to NYC or Denver areas) or Remote-US

Position Summary:

The Business Analyst provides support gathering and documenting business and reporting requirements that align with state and federal guidelines. This individual will analyze complex problems and issues using available information from both internal and external sources. Other responsibilities will include – creating specifications documents for business processes, reports, data extracts, and analyses based on business needs. Identify and interpret trends in datasets to find possible outliers or patterns that can be used to drive process improvements. Collaborates with internal and external cross-functional teams (compliance, product, sales, marketing, underwriting, implementation, client services, clinical operations) to design, refine, automate, and maintain operational capabilities.

Position Responsibilities:

• Monitors for changes in existing business processes and updates documentation accordingly - Finds new opportunities for process developments and improvements
• Intake, analyze and manage requests from stakeholders
• Proactively reviews business processes and data to develop subject matter expertise of processes supported by our team
• Drives root-cause-analysis and resolution of data and processes issues/errors by partnering with key stakeholders
• Supports analytical, problem-solving functions by defining and documenting specifications pertinent to all departmental processes
• Analyzes business workflow and system needs for conversions and migrations to ensure that government submissions, recovery, and cost savings regulations are met
• Prepares end user documentation and training materials as needed
• Support government data submission processes by analyzing complex data issues using data from internal and external sources
• Improve government data submission processes by reviewing and synthesizing state and federal recourses, consolidating into comprehensive business requirements documents
• Support creation of intake request to enhance existing processes by gathering requirements and level setting with stakeholders on required processes
• Develop and set up performance metrics for stakeholder distribution
• Performs root cause analysis of government data processing and submission issues; develops recommendations based on data and industry knowledge

Minimum Qualifications:

• 3+ years of healthcare experience
• 3+ years of business process analysis, preferably in healthcare
• 3+ years of experience with Government Exchange programs
• Demonstratable knowledge of SQL, Excel, and flow-charting tools
• Experience with implementation/project management
• Experience working with cross-functional teams
• Extremely flexible, highly organized, excellent communication and able to shift priorities easily
• Attention to detail & commitment to delivering high-quality work product
• Comfort or experience in a fast-paced, growing environment
• Intellectual and professional curiosity
• Familiarity with the agile framework/Certified Scrum Product Owner preferred
• Bachelor’s degree in Business Administration, Data Analytics, Computer Science or 3+ years of relevant experience

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

Position Summary:

The Senior Manager is responsible for leading the end‑to‑end implementation, governance, and change management of regulatory requirements for Exchange plans and EDGE Server operations. This role oversees the delivery of CMS submissions, compliance activities, contract applications, and bid‑related client support, while also coordinating responses to federal and state regulatory audits. The Senior Manager ensures all regulatory reporting obligations are met for Exchange clients by interpreting CMS and state guidance, partnering with internal subject matter experts and client teams, and translating requirements into operational processes. Using structured research, analysis, testing, and validation, this role ensures that systems, workflows, and data submissions consistently meet regulator expectations and client objectives.

Position Responsibilities:

• Lead Government Programs support for Exchange business functions including claims adjudication, regulatory reporting, and audit support (Government, and Client).
• Leads the interpretation, implementation and monitoring of all relevant regulatory requirements and changes impacting Capital Rx’s Exchange Programs.
• Establish and maintain the EDGE pharmacy submission playbook (file intent, lineage, duplicate controls, timestamp standards, enrollment alignment).
• Define and enforce submission cadences, pre‑submission QA gates, and accept/active/non‑orphan targets that meet CMS sufficiency timelines.
• Translate CMS updates into operational SOPs and training.
• Partners with cross‑functional SMEs to analyze regulatory changes, determine their implications for organizational processes, systems, and client commitments, and leads the coordinated, on‑time implementation of required updates across the enterprise.
• Manages timely response to Government Programs support for RFP/RFI, internal sales, and Exchange client requests.
• Provides key insights on Exchange functions using data analysis, industry knowledge and subject matter expertise to identify opportunities, and develop solutions, for optimization of internal business processes and systems.
• Supports the documentation management of internal policies and procedures, reporting and project specifications, job aids, and workflows for designated Government Programs Operations.
• Leverages profound knowledge of Exchange guidance and understanding of industry and market requirements to support product strategy and service delivery.
• Maintains current knowledge of Exchange requirements to facilitate compliance of ongoing business operations.
• Fosters a high-performance culture through mentoring and collaboration, providing team members with ongoing performance feedback and identifying required changes to existing roles and responsibilities to ensure effectiveness and efficiency.
• Assesses impact of new business to understand scalability and staffing needs.

Required Qualifications:

• 6+ years of relevant Prescription Benefit Management and/or Health Plan experience supporting Exchange plans
• 5+ years people management experience
• Vast knowledge of Exchange regulatory requirements and associated product and/or operational workflows
• Proven success managing multiple complex projects simultaneously
• Extremely flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product
• Excellent written and verbal communication skills
• Proven success managing cross functional teams and maintaining effective relationships at all levels both internal and external; including government entities

This range represents the low and high end of the anticipated base salary range for the NY - based position. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and if the location of the job changes.

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

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• 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), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.

Judi Health 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.