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Location: Remote (For Non-Local) or Hybrid (Local to NYC area) Position Summary: The role of Government Programs Operations Manager is instrumental in ensuring the compliant and efficient administration of pharmacy benefits within the framework of ever-evolving Medicaid and Exchange regulatory landscapes. This individual will be required to have an in-depth understanding of regulations and how they govern operations within the respective markets in which we operate. Primary responsibilities will include the implementation and oversight of complex government program functions that adhere to regulatory guidelines. Utilizing research, analysis, testing, and validation to guarantee program effectiveness and compliance. Aligning program operations with overall business objectives while maintaining strict adherence to federal and state regulations. This combined approach ensures that the manager possesses the necessary expertise to implement effective processes, while fostering collaborative relationships with cross-functional areas in the organization. Position Responsibilities:
Review contract and regulatory language to extract points requiring action or needing development work to maintain compliance
Maintain current knowledge of Medicaid and Exchange requirements to facilitate compliance of ongoing business operations
Monitor internal government program operations to identify gaps and/or resolve any identified operational discrepancies, including root cause analysis and implementation of necessary actions
Leverage in-depth understanding of the Medicaid and Exchange regulatory environments to support product strategy and service delivery
Collaborate with cross-functional teams to oversee the timely implementation of regulatory & sub-regulatory guidance
Support audits of government programs (government, client or internal)
Manage validation, submission, error handling, and change management for regulatory deliverables
Perform highly complex data analysis to ensure implemented solutions are functioning according to defined specifications
Help drive the implementation of internal process monitoring including the development of dashboards and reporting
Identifies opportunities for improvement and participates in the development of new solutions/capabilities in support of government program compliance and audit readiness
Document policies and procedures, reporting and project specifications, job aids and workflows within the department
Foster a culture high-performance through mentoring and collaboration.? Provide team members with constant and consistent performance feedback/direction.
Support with the assessment new business impact to understand scalability and staffing needs
Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
Required Qualifications:
4+ years of relevant PBM and/or Health Plan experience supporting Medicaid programs within the domain of pharmacy benefits
Thorough knowledge of Medicaid regulatory requirements and associated product and/or operational workflows within the domain of pharmacy benefits
Knowledge of relevant tools such as the Microsoft (MS) Office suite of product, MS Visio, JIRA, Confluence, etc.
Experience leveraging analytical tools such as SQL, R, or Python to analyze data
Familiarity with state pharmacy encounter submissions
Ability to balance multiple complex projects simultaneously
Extremely flexible, highly organized, and able to shift priorities easily
Attention to detail & commitment to delivering a high quality and timely work product
Excellent written and verbal communication skills
Proven experience within a similar role
Strong analytical, problem-solving, and critical thinking skills
Proficiency in requirement gathering and documentation techniques
Ability to collaborate effectively with cross-functional teams
Familiarity with the Agile software development methodology
Preferred Qualifications:
6+ years of relevant PBM and/or Health Plan experience supporting Medicaid and Exchange programs within the domain of pharmacy benefits
Thorough knowledge of Medicaid and Exchange regulatory requirements and associated product and/or operational workflows within the domain of pharmacy benefits
Base Salary: $95,000 - $100,000 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. 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. #LI-SE1
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Capital Rx
Feb 28, 2025