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Senior Claims & Encounters Analyst

Remote

About Us:

Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, a public benefit corporation that provides full-service pharmacy benefit management (PBM) solutions to self-insured employers; Judi Health™, which offers comprehensive health benefit management solutions for employers, TPAs, and health plans; and Judi®, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.

Location: Hybrid (Local to NYC or Denver areas) or Remote-US

Position Summary:

The Senior Claims and Encounters Analyst will assist the Claims and Encounters team lead with all operational functions related to government programs. This role requires deep expertise in regulatory compliance for all claims and encounters operations. Cross-functional collaboration will be essential to ensure the integrity and efficiency of all government program processes. The Senior Analyst will also mentor team members and contribute to strategic initiatives that enhance Capital Rx’s government programs operations.

Position Responsibilities:

  • Support the team lead with day-to-day operational tasks related to claims processing, including testing, troubleshooting, documentation and Encounter Data submissions.

  • Oversee error handling and change management for Encounters, ensuring compliance with CMS, State and client requirements.

  • Conduct root cause analysis and implement corrective actions for operational issues, collaborating across departments to drive resolution.

  • Monitor claims processing and adjudication trends, identifying systemic issues and opportunities for process improvement.

  • Manage complex claims corrections, including retro-eligibility changes, COB adjustments, and other regulatory-driven updates.

  • Serve as a subject matter expert (SME) for Medicare, Medicaid and Exchange operations, supporting internal teams and external stakeholders.

  • Support development and testing of operational processes, tools, and project deliverables.

  • Establish and promote best practices for government programs operations, ensuring scalability and compliance.

  • Support product strategy and service delivery by leveraging deep knowledge of Medicare & Medicaid regulatory environments.

  • Stay current on CMS/State regulatory guidance updates, translating changes into actionable operational strategies.

  • Mentor and guide analysts, fostering professional development and knowledge sharing.

  • Maintain current knowledge of Medicare, Medicaid and Exchange requirements to facilitate compliance of ongoing business operations.

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

 

Minimum Qualifications:

  • 5+ years of experience in PBM or Health Plan operations, with a focus on Medicare Part D and/or Medicaid programs.

  • Proven expertise in Medicare regulatory requirements and operational workflows, including PDE, and Encounter Data.

  • Advanced MS Excel skills (pivot tables, complex formulas, data modeling); familiarity with SQL or other data tools is a plus.

  • Demonstrated ability to lead cross-functional projects and manage competing priorities in a fast-paced environment.

  • Strong analytical and problem-solving skills, with a track record of driving operational improvements.

  • Excellent communication and stakeholder management skills, including experience presenting to leadership.

  • Experience mentoring or managing junior team members is preferred.

  • Deep understanding of CMS compliance requirements and audit readiness.

  • Highly organized, detail-oriented, and committed to delivering high-quality work.

 

Salary Range

$85,000 - $95,000 USD

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.

Judi Health 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. 

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