Medical Network Operations Manager

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.

Position Summary:

Capital Rx is seeking a self-driven Medical Network Operations manager to support the medical claims adjudication workflow for JUDI Health, Capital Rx’s enterprise health platform.

In year one, this individual will focus on ensuring robust and efficient provider operations to meet the needs of the payers, customers, and members. They will also train on JUDI Medical adjudication system, Network as well as Point solution vendor systems, and build out a team of medical network operations specialists in support of In-Network and Out of Network operations directly or via Clearing House solutions.

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 from a Network operations standpoint.

Position Responsibilities:

• Subject Matter Expertise: Must have strong knowledge on Provider operations from Care delivery to Revenue Cycle management functions, including payments, recoupments, and Coordinate of Benefits (COB) claims.

• Vendor Relationship management: Establish, develop, and maintain close partnerships with the key medical Network, point solution vendors, and Clearing houses. Serve as the main contact addressing issues, resolving disputes, and ensuring smooth operations.

• Contractual obligations and Compliance: Carefully review contractual terms and SLAs established with the vendors and ensure they are always adhered to. Work with the internal teams to develop external facing reports and score cards, and conduct QBR/MBR meetings as needed

• New customer implementations: Support JUDI Health’s Sales team, coordinate with the Business Development Managers of major medical network and point solution vendors that JUDI Health partnered with regarding new customer onboardings.

• Innovation: Work with the mindset that status-quo is unacceptable and continue to identify process deficiencies in the current state and innovate new solutions for the issues identified.

• Regulatory Compliance & Reporting: Stay updated on changes in healthcare, ensure Medical Networks and Point solution vendors operate within regulatory guidelines, industry standards, and payer requirements.

• Internal team collaboration: Break silos and ensure coordinated efforts across the organization. Provide input on Claims processing, billing/invoicing, and quality improvement initiatives as they related to Network Operations

• Product development: Partner with product managers and directors operating in an agile framework to conceptualize and break down functional and non-functional requirements needed to adhere to all contractual and federal payments regulations.

• Team management: Manage team goals in line with set objectives for the business, evaluate individual performance, and support growth and productivity.

• 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:

• Experience managing a team of direct reports working in a remote setting

• 5+ years of work experience at a Payer Solutions company or TPA

• Well-versed on data exchanges, file or real-time transaction processing (RTP) using APIs