Current openings at Judi Health

Position Summary: We are seeking a detail-oriented and analytical Manager, Pharmacy Pricing Appeals to join our Provider Relations team. In this role, you will be responsible for managing and resolving the interaction with the pharmacies related to pricing appeals and claims review requests submitted by the pharmacies or internal teams. This includes performing an initial review of the claim and associated pricing, providing the information to internal teams for review, managing any claim adjustments that may be needed, and communicating any necessary information back to the pharmacies. You will play a critical role in ensuring fair reimbursement practices and maintaining strong relationships with pharmacy partners.  Position Responsibilities: Lead the review and improvement of the pharmacy pricing appeal process in coordination with the Analytics team. Lead the review and evaluation of the pricing appeal regulatory requirements with the Legal team. Manage intake pharmacy pricing appeals or claims reviews from the pharmacies or internal teams via the applicable intake methods required by internal processes and regulations. This involves managing applicable appeal in-boxes and intake methods. Evaluate pharmacy-submitted appeals to ensure they meet established criteria and provide the applicable information to the appropriate internal teams for review. Receive the internal claim pricing review and respond to the appealing pharmacy with the information. Manage the internal process to update any pricing or make claim adjustments as necessary. Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes. Provide appeal response information and feedback to the pharmacies as required. Provide clear and timely updates to pharmacies and other stakeholders regarding appeal statuses and outcomes. Maintain accurate records of appeals and generate reports on trends and discrepancies. Lead the development of and manage the claims review process at the NDC level. Support other projects as assigned by the Provider Relations team. Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance. Minimum Qualifications: Bachelor’s degree required. 5+ yrs. of experience in reviewing claims or payment appeals in healthcare, pharmacy, PBM, or other relevant experience. Such prior experience in a pharmacy pricing appeals role includes experience in managing regular correspondence and communication with pharmacies. In-depth knowledge of pharmacy operations and drug pricing. Familiarity with PBMs and their role in pharmacy reimbursement. Strong analytical and problem-solving skills. Strong project management skills. Excellent communication and interpersonal abilities. Experience with and understanding of pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows. Knowledge of state or federal pricing appeal laws. Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint. Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out contracts and tasks. Ability to work independently, track work/projects appropriately and remain on task. Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders. Preferred Qualifications: Certification in pharmacy technician or related field is a plus.

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

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.