Claims Adjudication Associate

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.

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

Position Summary:

Capital Rx is seeking a self-driven Claims Adjudication associate to support the Medical claims adjudication workflow for JUDI Health, Capital Rx’s enterprise health platform.

In year one, this individual will train on the JUDI Medical adjudication system. This individual will 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 and contractual 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.
• Provide support to Customer Care representatives in relation to claims and benefits questions from Members and Providers.
• 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.
• Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission.
• Adhere to standard SLA’s regarding number or percentage of claims processed per day
• Assist in management of claims related mail workflows including Appeals, subrogation, payments, and stop-loss.
• Build and maintain trusting relationships with clients through superior customer service.
• Assist in 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.
• 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:

• Bachelors degree strongly preferred
• Experience managing a team of direct reports
• 1+ years of work experience at a health plan, claims adjudicator, or TPA
• 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

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.

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.