Position Summary

Acts as a dedicated specialist responsible for leading administrative and operational tasks to facilitate the execution of clinical programs and clinical initiatives, including but not limited to, triaging incoming calls, conducting outreach, managing and maintaining drug lists, and supporting reporting requirements.

Position Responsibilities:

• Work with the Clinical Programs team to triage incoming clinical programs calls, schedule appointments for consultations and conduct outreaches to prescribers, pharmacies, and members 
• Lead administrative and operational tasks to support the implementation of clinical programs, including but not limited to Capital Rx’s pharmacogenomics, MTM (Medication Therapy Management), lower cost alternative solutions, opioid safety edits, cost containment, and other clinical initiatives as needed
• Manage and maintain drug lists to support operations of clinical programs including periodic drug list maintenance, weekly and quarterly list reviews, and ad-hoc updates
• Support reporting requirements, monitor claims, and ensure communication amongst all stakeholders including internal and external partners
• Identify, document, and effectively communicate issues to appropriate internal stakeholders ensuring customers receive quality care and resolution meets all health and safety standards
• Work collaboratively with internal business and clinical partners to support clinical program initiatives as required
• Ensure customer satisfaction, demonstrate genuine compassion and care, and provide professional customer service in a fast paced, startup environment
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies
• Uphold general business needs and operations as required

Required Qualifications:

• Active, unrestricted pharmacy technician license
• 2+ years of applicable experience in a clinical pharmacy setting PBM, health plan, or related health care experience
• 1+ year of customer service experience with a passion for building customer loyalty through exceptional listening, relationship building, and strong written and verbal communication
• Ability to balance multiple complex projects simultaneously with minimal direction

Preferred Qualifications:

• Medication Therapy Management (MTM) experience preferred
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and PowerPoint
• Experience with Confluence, Jira, Tableau, Salesforce
• Highly detail-oriented and analytical
• Bilingual- Spanish preferred

Base Salary: 

• Remote - $60,000 - $70,000 (final salary within this range is determined by the candidate's geographic location and applicable market tier)

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

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

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full-time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Judi Health provides full-time employees with the following benefits at no cost to the employee: basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short-term disability, long-term disability, an employee assistance program, and a wellness program. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

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.

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.

Position Responsibilities:

• Lead administrative and operational tasks to support the implementation and operations of clinical programs, including pharmacogenomics, MTM, adherence, opioid safety, concurrent and retrospective drug utilization review, and other initiatives as needed
• Support clinical programs business development needs, including client contracting, vendor management, preparation of opportunity analyses, and program sales support
• Validate program identification and claim files, fax and letter communication proofs, vendor invoices, and client invoices for accuracy on a reoccurring basis
• Generate data outputs and analyze large data sets to monitor program quality and identify enhancement opportunities
• Manage large scale projects to support business needs
• Maintain drug lists to support operations of clinical programs including periodic drug list maintenance, weekly and quarterly list reviews, and ad-hoc updates
• Ensure customer satisfaction, demonstrate genuine compassion and care, and provide professional customer service in a fast-paced environment.
• Uphold general business needs and operations as required

Required Qualifications:

• 2+ years of applicable experience in a clinical pharmacy setting PBM, health plan, or related health care experience
• 1+ years of prior experience in business analysis, project management, or related fields
• Ability to manage multiple complex projects simultaneously with minimal direction
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and PowerPoint
• Active, unrestricted pharmacy technician license

Preferred Qualifications:

• Proficient in querying large data sets, and coding languages are a plus
• Experience with Confluence, Jira, Tableau, Salesforce
• Experience with specialty pharmacy, home infusion, and related care coordination services
• Highly detail-oriented and analytical 

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

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full-time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Judi Health provides full-time employees with the following benefits at no cost to the employee: basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short-term disability, long-term disability, an employee assistance program, and a wellness program. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

Location: Remote (U.S only)

Position Responsibilities:

• Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines
• Make outbound calls to providers to obtain additional clinical information to ensure substantial clinical information exists to reach a clinical determination for pharmacist review
• Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.
• Review and analyze pharmacy claims data for proactive outreach and intervention.
• Identify, document, and escalate provider concerns to the appropriate internal team including various members of the Prior Authorization Team
• Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.
• Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies
• Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast paced, startup environment
•  

Required Qualifications:

• 2+ years of pharmacy technician experience in a PBM, health plan, or in another clinical pharmacy setting
• Experience handling prior authorization requests/understanding of prior authorization requirements required
• National Certified Pharmacy Technician (CPhT) license, required
• High school diploma or the equivalent; Associate’s or bachelor’s degree is preferred
• Excellent communication, writing, and organizational skills
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven call center environment
• Ability to multi-task and collaborate in a team with shifting priorities

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. 

Position Summary:

The QA Pharmacist will use their state regulatory knowledge to perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals. The QA Pharmacist will utilize a strong comprehension of regulatory requirements to ensure success in annual reporting, program audits, and ad hoc audits.

Position Responsibilities:

• Complete monthly utilization management and appeals performance and process audits in alignment with applicable regulations, accreditation standards, and best practices. 
• Create and maintain progress reports and audit results in accordance with regulatory/accreditation requirements and internal processes.
• Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory/accreditation requirements (CMS, URAC, NCQA).
• Continuously review and remain informed of all regulatory/accreditation requirements and updates impacting the coverage request and appeals processes.
• Respond to inquiries from internal and external stakeholders regarding quality assurance processes, audit results, and compliance policies and procedures.
• Work independently and with team members as warranted by audit assignment. 
• Assist in designing and implementing audit tools and programs, creating QA scorecards and guides in collaboration with all department stakeholders. 
• Provide ongoing performance feedback, to team leads to ensure consistent performance.
• Assist management in identifying, evaluating, and mitigating operational, and compliance risks.
• Work in collaboration with operational leaders to identify training opportunities and recommend improvements to Work Instructions, Job Aids, and Policy and Procedures to improve performance.

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 2+ years of state regulatory and audit utilization management experience at a PBM or health plan required
• Extensive knowledge of how to operationalize regulatory requirements
• Strong oral and written communication skills required
• Intermediate to advanced Microsoft Excel skills required
• Possess strong analytical skills, attention to detail, quantitative, and problem-solving abilities 
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven work environment
• Ability to multi-task and collaborate in a team with shifting priorities

Preferred Qualifications:

• Familiarity/experience with URAC and NCQA accreditation requirements
• Utilization management and/or appeals audit experience
• 3+ years of compliance or regulatory experience at a PBM or health plan

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.

#LI-BC1

Position Summary:

Join our first-of-its-kind Integrated Benefits team as a Benefit Operations Specialist, where you will play a pivotal role in delivering comprehensive medical and pharmacy benefit programs for Judi Health clients. You will lead benefit configuration, claims testing, and quality assurance processes, ensuring accuracy and efficiency across all implementations. This position offers the opportunity to influence operational best practices and contribute to a team that is redefining how integrated benefits are delivered in the healthcare space.

Position Responsibilities:

• Responsible for all aspects of benefit configuration, including new plan setup, plan change setup, claims testing, and regular audits
• Drives cross-functional collaboration with the product/dev team as well as additional stakeholder teams to ensure client customized requests are configurable for both new plan setups and plan changes
• Clearly communicate benefit configuration setup and testing process or specific test claims to clients in a concise way that can be understood by users who are not experts in benefit areas
• Make recommendations to streamline the work processes and systems that impact plan/benefit design to create efficiency and quality outcomes
• Works cross-functionally to create new benefit options aligning with market needs, including expansion in government programs
• Develop standards and custom batch testing scenarios and inputs, reviewing test claims output to validate claim accuracy against the clients’ benefit design
• Develops standard policy and procedures, training materials and provide education for training and presentation to cross-functional teams
• Maintain acceptable and appropriate quality levels and production SLA response time
• Participate in client meetings to assess new client benefit information or change requests to ensure design of Judi logic ties to the benefit configuration intended to meet client needs
• Partner with leadership to develop benefit plan designs and ensure that the plan designs meet client requests, Health Plan strategic/business parameters, and all regulatory and other oversight agencies’ requirements
• Partner with Client Services team as clients go live and troubleshoot benefit-related discrepancies, errors, and problems
• Support general business or team needs, as assigned
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Qualifications:

• Bachelor’s degree preferred
• 5+ years of TPA / health plan experience in Medical Benefit configuration, benefit testing, claims monitoring, SPD creation, Medical Coding or other applicable department needs
• 3+ years of experience with Cigna a plus
• Pharmacy, Dental, or Vision experience a plus
• Self-funded plans, Medicare/Government programs and ERISA experience preferred
• Tremendous attention to detail, ability to shift priorities easily and ability to work in high paced, deadline drive environment.
• Exceptional written and verbal communication skills
• Experience working with product/dev teams and familiarity with Agile, preferred
• Preferred: experience working with structured or unstructured data in Excel, SQL, and other data visualization tools

Certifications:

• IFEBP certification a plus

Position Summary:

This individual will report to the Associate Director of Clinical Programs Business Development and be responsible for supporting the sales and profitability of Capital Rx’s suite of clinical programs. This role serves as a primary business development lead for clinical offerings, from opportunity identification, client presentations, to negotiations and contracting.  This role will drive clinical programs sales to new and existing PBM clients and foster strategic relationships with consultant groups. The ideal candidate will combine clinical expertise with strategic sales acumen to expand program adoption and deliver measurable value to clients. This is a base salary plus commission role. 

Position Responsibilities:

• Drive the sales strategy for Capital Rx’s suite of clinical programs end-to-end from prospecting through close.
• Proactively assess client data to identify opportunities, meet with account teams to qualify opportunities, and deliver compelling presentations, proposals, and ROI analyses to prospects to drive clinical program sales.
• Develop and implement strategic plans to identify, engage, and close new clinical program opportunities.
• Cultivate and manage trusted relationships with pharmacy benefit consultant groups, serving as a subject matter expert for our clinical programs.
• Maintain a strong understanding of market dynamics, competitive landscape, and client needs to inform sales strategy.
• Contribute to strategic client retention initiatives by aligning clinical programs with client goals.
• Demonstrate strong analytical, presentation, and CRM skills to support sales execution and tracking.
• Maintain a deep understanding of clinical programs, regulatory requirements (e.g., CMS, NCQA, URAC), and industry trends to effectively position our solutions.
• Serve as a liaison between the field and internal product/clinical teams to ensure offerings remain competitive and relevant.
• Support implementation handoffs to ensure smooth onboarding of new clients.
• Provide market feedback to inform future product development and innovation.
• Support general business needs and operations, as required.
• All employees are responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Minimum Qualifications:

• MBA degree and/or certification in sales or business
• 3+ years of applicable experience in a health plan or PBM, or healthcare sales and/or completion of a PGY1 Clinical Pharmacy Residency Program, Managed Care Residency or Fellowship with additional 2+ years of applicable experience
• Exceptional negotiation, presentation, and communication skills with the ability to articulate clinical value propositions to diverse audiences.
• Experience engaging or partnering with pharmacy consultant firms
• Working knowledge of pharmacy benefit management, Medicare Part D, and commercial pharmacy benefits
• Ability to analyze data and market trends to inform sales strategy and client recommendations.
• Proven track record of meeting or exceeding sales targets and successfully closing complex B2B deals.
• Maintain an active, unrestricted pharmacy license in the state of residence
• Ability to balance multiple complex projects simultaneously with minimal direction
• Ability to travel up to 50%

Preferred Qualifications:

• PharmD
• Experience working with HEDIS, Stars and PQA pharmacy quality measures
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and PowerPoint
• Experience with Confluence, Jira, Tableau
• Highly detail-oriented and analytical

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 Summary:

Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity. Work with appeals team for multiple lines of business such as Commercial, Exchange and Medicare, ensuring the proper submission of appeals for review by pharmacist and medical directors.

Position Responsibilities:

• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Review all cases received, to verify if case meets qualifications for appeal review.
• Performs triple check to ensure quality reviews and handling in accordance with policies and procedures.
• Updates case types, sends appeal acknowledgements, and submits case information to independent review organizations.
• Communicate effectively with appeal pharmacists regarding internal and external appeals.
• Make verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call.
• Exhibit excellent phone and communication skills while providing complete and accurate information to members and providers.
• Performs all other related duties as assigned

Minimum Qualifications:

• 1 + years’ experience working as a certified pharmacy technician in a managed care or PBM setting required.
• Active, unrestricted certified pharmacist technician license required.
• Excellent organization details and strong detail orientation.
• Strong oral and written communication skills.
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities.
• Ability to work 12pm-9pm EST hours

Preferred Qualifications:

• Experience working with commercial and medicare appeals preferred

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

Remote, US Salary Range
$60,000.00 - $65,000.00  USD
New York, NY Salary Range
$78,800.00 - $98,500.00 USD
Denver, CO Salary Range
$72,000.00 - $90,000.00 USD

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.

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology, and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Responsibilities:

• Lead and nurture a dynamic team of clinical pharmacists and technicians dedicated to the prior authorization and appeals process.
• Create and uphold robust policies and procedures for utilization management review.
• Utilize available data to optimize prior authorization staffing and streamline workflow.
• Actively participate in goal setting and regularly evaluate the performance of the PA team.
• Respond to requests for information (RFI) and requests for proposal (RFP) regarding prior authorization processes.
• Generate and deliver comprehensive reports on prior authorization metrics to both internal and external stakeholders.
• Manage contracts with external Independent Review Organizations and clinical resource vendors
• Supervise the UM quality management process to ensure compliance with state, federal, and regulatory guidelines.
• Participates in the quality improvement committee and supports quality improvement projects as required by URAC.
• Oversee clinical criteria and decision tree creation and maintenance.
• Lead the recruitment and onboarding process for pharmacists and technicians.
• Support the training and growth of both new and existing staff members in adherence to proper procedures.
• Investigate and resolve escalated issues from clients and clinical partners as needed.
• Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed.
• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Schedule requires working Monday through Friday with occasional on‑call responsibilities and the flexibility to work outside of regular business hours based on business needs.

Required Qualifications:

• Active, unrestricted, pharmacist license required
• Bachelor of Pharmacy or Doctorate of Pharmacy Degree required
• 4+ years of prior authorization experience at a PBM or health plan
• 3+ years of leadership experience preferred
• Experience with multiple lines of business including Commercial and Medicare Part D preferred
• Exhibit strong written communication and oral presentation skills
• Proficient in Microsoft office Suite with an emphasis on PowerPoint and Excel
• Ability to work in a fast-paced environment with shifting priorities
• Attention to detail & commitment to delivering high-quality work

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.

Remote, US Salary Range
$155,000.00 - $170,000.00 USD  
New York, NY Salary Range
$128,000.00 - $160,000.00 USD  
Denver, CO Salary Range
$117,600.00 - $147,000.00 USD  

Position Summary:

Capital Rx is seeking a strategic, client-focused Clinical Account Consultant to support all aspects of clinical functions to service client clinical needs. In this role, you'll ensure client satisfaction, retention, and trend management, while providing clinical support to clients across all lines of business. You’ll collaborate directly with clients to develop and implement formulary and clinical strategies, support contract renewals, and contribute to clinical process improvements. If you’re passionate about delivering exceptional service with a focus on clinical excellence and driving healthcare innovation, we’d love to hear from you!

Position Responsibilities:

• Support clinical aspects of implementation for new clients, plans, plan changes, and other clinical plan set-up requirements. This may include gathering client clinical intent and plan requirements, building/coding plans and formularies, conducting peer-review quality control, and reviewing testing and claims output.
• Actively address all clients’ clinical needs including the management and implementation of custom formularies, clinical criteria, and clinical strategies.
• Comprehend and effectively explain formulary, benefit, and clinical programs to clients, including intervention components, member and plan experience, book of business experience, and regulatory requirements as it directly pertains to clinical functions.
• Meet with clients to discuss clinical trends, review relevant pharmacy data, and provide recommendations with supportive rationale for formulary, clinical and plan management strategies.
• Analyze and interpret pharmacy claims data to identify clinical and plan trends and to offer insights for individual clients and across multiple clients. 
• Communicate drug information to clients and respond to plan-specific clinical inquiries; support resolution of member-specific inquiries.
• Collaborate with cross-functional teams to support sales initiatives, requests for information (RFI), requests for proposal (RFP), and prospect presentations.
• Actively attend and contribute to sales meetings and client presentations with a focus on clinical operations and clinical account management.
• Lead key internal clinical operations initiatives and general business needs/operations, as required.
• Identify and contribute to clinical process improvement efforts.
• Certain times of year may require meeting participation, testing, claims review, or other requirements outside of standard business hours, including weekends.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications:

• Doctor of Pharmacy (PharmD) degree from an accredited institution
• Current, unrestricted registered pharmacist license(s)
• Relevant experience of 3-5 years in a health plan or pharmacy benefits management (PBM)
• Direct account management experience supporting clients across multiple lines of business
• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel
• Experience working with large datasets and analyzing raw data in Excel
• Ability to balance multiple complex projects simultaneously
• Exceptional written and verbal communication skills
• Flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product
• Ability to travel and present to small and large groups

Preferred Qualifications:

• Completion of managed care residency, preferred
• Prior account management experience of at least three (3) years, preferred
• Prior experience with Medicare line of business, preferred

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.

Remote, US Salary Range
$145,000.00 - $165,000.00 USD  
New York, NY Salary Range
$139,600.00 - $174,500.00 USD  
Denver, CO Salary Range
$128,000.00 - $160,000.00 USD  

Location: Remote (For Non-Local) or Hybrid (Local to New York, NY or Denver, CO area)

Position Summary

The Benefit Configuration Specialist is responsible for supporting the testing and validation of pharmacy benefit plan configurations across multiple lines of business, including Commercial, Medicaid, Exchange, and Medicare. This role ensures that benefit plan setups align with client intent, regulatory requirements, and internal configuration standards.The Specialist will execute comprehensive benefit testing, participate in pre-implementation audits, and validate plan accuracy prior to deployment. Responsibilities include reviewing plan design specifications, performing scenario-based testing, identifying configuration discrepancies, and collaborating with cross-functional teams to resolve issues. This position requires strong attention to detail, analytical thinking, and the ability to interpret complex pharmacy benefit structures. The ideal candidate is comfortable working in a fast-paced environment, managing multiple audits simultaneously, and communicating findings clearly to internal stakeholders.

Position Responsibilities:

• Execute end-to-end testing and validation of pharmacy benefit plan configurations across Commercial, Medicaid, Exchange, and Medicare lines of business.
• Perform detailed implementation audits to ensure benefit setup aligns with client intent, regulatory requirements, and internal configuration standards.
• Review and interpret plan design documents, benefit change forms, and formulary specifications to translate requirements into executable test scenarios.
• Analyze claim outputs to confirm expected adjudication behavior and accumulator movement.
• Identify, document, and communicate configuration discrepancies or defects; collaborate with configuration team to ensure timely resolution.
• Ensure compliance with applicable federal and state regulations, including guidance from the Centers for Medicare & Medicaid Services (CMS) where applicable.
• Maintain clear documentation of testing results, audit findings, and approval signoffs.
• Participate in client-facing meetings to review testing scope, discuss audit findings, clarify benefit intent, and provide detailed explanations of testing results and configuration outcomes.
• Partner with cross-functional teams to ensure benefit accuracy and successful implementation.
• Contribute to process improvements that enhance testing efficiency, audit quality, and overall benefit validation standards.
• Manage multiple audits and testing initiatives simultaneously in a deadline-driven environment.
• Responsible for adherence to the Capital Rx Code of Conduct

Required Qualifications:

• Bachelor’s degree in Healthcare Administration, Business, Information Systems, or related field (or equivalent work experience).
• Minimum 3–5 years of experience in pharmacy benefit management (PBM), health plan operations, or benefit configuration.
• Direct experience supporting Medicare lines of business (Medicare Part D and/or MAPD).
• Demonstrated understanding of Medicare benefit structures.
• Experience testing and validating pharmacy benefit configurations in Commercial, Medicaid, Exchange, and/or Medicare lines of business.
• Strong knowledge of formulary design, tier structures, utilization management (PA, ST, QL), and accumulator logic.
• Ability to analyze benefit design documents and translate requirements into executable test scenarios.
• Strong analytical skills with high attention to detail and accuracy.
• Proficiency in Microsoft Excel for data review, validation, and reporting.
• Strong written and verbal communication skills with ability to clearly document findings and discrepancies.
• Participate in client-facing discussions to review benefit testing outcomes and implementation readiness while providing clear guidance on complex benefit designs.

Base Salary:

• New York, NY (hybrid) $78,800 - $98,500
• Denver, CO (hybrid) $72,000 - $90,000
• Remote -  $62,400.00 - $90,000.00

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

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

Benefits

Judi Health provides all full-time and part-time benefit-eligible employees with the ability to elect medical and pharmacy coverage, dental insurance, vision insurance, accidental injury insurance, critical illness insurance, hospital indemnity insurance, and flexible spending accounts. Full-time employees also have access to a health savings account, voluntary life insurance, and voluntary accidental death and dismemberment insurance for themselves and their eligible dependents.

Judi Health provides full-time employees with the following benefits at no cost to the employee: basic life insurance, basic accidental death and dismemberment insurance, paid time off, sick time, holidays, short-term disability, long-term disability, an employee assistance program, and a wellness program. Full-time employees are also eligible for a 401(k) plan with company match after one year of full-time employment.

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.

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.