Manager, Claims Operations Data Exchange

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

Position Summary:

The Manager, Data Exchange at Capital Rx plays a pivotal role in ensuring the accuracy, reliability, and seamless operation of data feeds essential to our pharmacy benefit services. This role is responsible for, but not limited to, claims reporting, manual claims processing, configurations, historical data loads, and connectivity setups for all Capital Rx clients. The Manager collaborates with both internal teams and external partners to develop, maintain, and troubleshoot data connections, ensuring the efficient flow of critical information such as claims, formulary, network, and eligibility data. The ideal candidate will have a strong understanding of PBM data, a proactive problem-solving approach, and excellent communication skills to facilitate collaboration across the organization and with external partners.

Position Responsibilities:

• Work with Data Exchange partners and internal teams to develop and maintain data feeds (e.g., claims, formulary, network, eligibility) and ensure their accuracy at Capital Rx.

• Serve as a point of coordination for Data Exchange issue identification and resolution with internal teams and external integration partners.

• Identify and triage Data Exchange issues, supporting the resolution of all errors related to data transfer, loading, and management.

• Interpret business requests, determine scope and impact, and categorize complexity to drive accurate SLA assignments.

• Proactively monitor system status and Data Exchange management data to quickly identify potential abnormalities that may impact quality and accuracy.

• Ensure all issues and errors are resolved using designated operating standards and within defined service levels.

• Assist with validating Data Exchange data integrity through regular audits and reconciliation processes.

• Participate in projects impacting Data Exchange, including vendor changes, client migrations, and client add-on requests.

• Act as a liaison between business areas within Capital Rx to ensure alignment, clear communication, and well-defined priorities.

• Demonstrate proactiveness in identifying opportunities for process improvement, problem-solving, and anticipating potential challenges in a dynamic work environment.

• Develop process documentation, including policies and procedures, to document JUDI configuration operational processes.

• Stay up to date with external regulatory guidelines (e.g., Medicare, Medicaid, state requirements) to ensure operational processes remain compliant with relevant rules and regulations.

• Adhere to the Capital Rx Code of Conduct, including reporting noncompliance.

Required Qualifications:

• Bachelor’s degree.

• 5+ years of experience, preferably in PBM, healthcare, with strong implementation of IT.

• Leadership experience within a PBM or healthcare setting.

• Ability to match key PBM concepts and data fields across various systems and file layouts to ensure consistency and accuracy of data transfers.

• Strong analytical skills to assess complex business problems and identify root causes.

• Proficiency in SQL, Excel, and other technical data skills preferred.

• Excellent communication skills with the ability to build effective relationships with internal and external stakeholders.

• Self-motivated, detail-oriented problem solver.

• Ability to manage multiple competing priorities in a dynamic environment and collaborate effectively in a team setting.

Base salary: $120,000 - $130,000

Visa Sponsorship: Capital Rx does not provide sponsorship to any candidates. This includes, but is not limited to those that require H1-B, TN, OPT, etc. Candidates must have authorization to work in the US at the time of application and throughout employment.

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

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 Cer