Government Programs Operations Manager – Analysis & Efficiencies

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

Position Summary: 

The Government Programs Operations Manager is responsible for overseeing the implementation, compliance, and optimization of Medicare, Medicaid, and Exchange programs. This position blends regulatory expertise with operational innovation to ensure that government program operations are both compliant and technically efficient. 

This manager will lead a team dedicated to identifying, developing, and maintaining technical analysis and efficiencies across the department. Responsibilities include designing automated solutions, validating the accuracy of outgoing deliverables, and establishing scalable processes that support regulatory and business objectives. The role also involves interpreting CMS and state guidance, collaborating with internal subject matter experts and clients, and ensuring that system capabilities align with both regulatory intent and client needs. 

In addition, the manager drives data-informed decision-making by overseeing the analysis of complex datasets to identify trends, outliers, and opportunities for process improvement. This includes creating detailed specifications for reports and operational tools and working closely with cross-functional teams—such as compliance, product, sales, marketing, underwriting, implementation, client services, and clinical operations—to enhance and maintain operational capabilities. 

 

Position Responsibilities: 

• Interpret and operationalize CMS/state regulatory and sub-regulatory guidance in collaboration with Compliance and internal SMEs 

• Oversee timely implementation of regulatory changes, coordinating cross-functional workplans across impacted departments 

• Monitor internal operations for government programs, identify and resolve errors through root cause analysis, and implement corrective actions 

• Support claims correction activities related to retro-eligibility and coordination of benefits (COB), while placing focus on the accurate reprocessing of claims 

• Support internal, client, and government audits by ensuring data accuracy, process transparency, and documentation completeness 

• Drive team to maintain comprehensive documentation including policies, procedures, job aids, workflows, and reporting specifications 

• Lead the development of automated tools and scalable solutions to improve operational efficiency and data accuracy 

• Analyze complex encounter and PDE data using internal and external sources to identify trends, outliers, and improvement opportunities 

• Define and document business and reporting requirements to support system enhancements and process improvements 

• Track performance metrics for encounter and PDE submissions, ensuring alignment with client and regulatory expectations 

• Foster a high-performance culture through mentorship, collaboration, and continuous feedback 

• Promote subject matter expertise within the team by encouraging proactive process reviews and knowledge sharing for purpose of establishing continuity within the team and its processes 

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

 

 

Required Qualifications: 

• 5+ years of healthcare data experience 

• 5+ years of relevant PBM and/or Health Plan experience supporting Medicare Part D, Medicaid, or Exchange plans 

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

• Experience working with cross-functional teams 

• 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  

• Excellent written and verbal communication skills 
• Ability to foster a culture of collaboration and high performing team 

 

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. 

About Capital Rx 

Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi®, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare 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 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.