Claims Adjudication Manager

Capital Rx
United States, New York, New York
285 Fulton Street (Show on map)
Nov 25, 2024
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 Claims Adjudication manager to support the Medical claims adjudication workflow for JUDI Health, Capital Rx's enterprise health platform. In year one, this individual will train on and help guide the future of the JUDI Medical adjudication system, and build out a team of claims adjudicators. This adjudication system is built in-house as a new module on the Capital-Rx JUDI platform. This individual will also be responsible for maintaining the operational adjudication process, member, and provider escalated inquiry management, subrogation, stop-loss, recoupment and adjustment flows, and adhering to standard claims processing SLAs. 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 medical claims processing. Position Responsibilities: Review, assess, and make decisions on medical claims submitted by networks, claimants, or other parties. The Claims Adjudicator reviews the facts of each case and applies the applicable laws, regulations, and policy provisions to determine the appropriate claim outcome. The Claims Adjudicator must be knowledgeable of the claims process, laws, and policies, as well as possess excellent communication skills and a commitment to providing outstanding customer service. The Claims Adjudication manager will be responsible for direct reports, and developing workflows, policies, and procedures related to the claims adjudication process. Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission Configure, test and validate Medical Adjudication workflows 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 JUDI platform. Lead communications throughout the implementation process, including detailed and strategic guidance for adjudication 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 adjudication 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 Benefit determinations Well-versed in impact of claims processing and adjudication in regards to COB, Adjustments, Appeals, and member/provider inquiries Act as a patient advocate, protecting privacy and confidentiality issues. 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 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: $106,000 - $125,000 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.