Benefit Operations Specialist

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

Position Responsibilities:

• Responsible for all aspects of benefit configuration, including new plan setup, plan change setup, claims testing, and regular audits for commercial, Medicare, Medicaid and Qualified Health plans

• Drives cross-functional collaboration with the Product/Dev teams as well as the Clinical Benefit teams to ensure client customized requests are configurable for both new plan setups and plan changes

• Clearly communicate benefit configuration setup and testing process or specific test claims to clients in a concise way that can be understood by users who are not experts in pharmacy benefits

• Make recommendations to streamline the work processes and systems that impact plan/benefit design to create efficiency and quality outcomes

• Works cross-functionally to create new benefit options aligning with market needs, including expansion in government programs

• Develop standards and custom batch testing scenarios and inputs, reviewing test claims output to validate claim accuracy against the clients benefit, clinical, network and pricing parameters

• Develops standard policy and procedures, training materials and provide education for training and presentation to cross-functional teams

• Maintain acceptable and appropriate quality levels and production SLA response time

• Participate in client meetings to assess new client benefit information or change requests to ensure design of JUDI logic ties to the benefit configuration intended to meet client needs

• Partner with Director, Benefits Administration and Operations to develop benefit plan designs and ensure that the plan designs meet client requests, Health Plan strategic/business parameters, and all regulatory and other oversight agencies’ requirements

• Partner with client account team as clients go live and troubleshoot benefit-related discrepancies, errors, and problems

• Support general business or team needs, as assigned

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

Required Qualifications:

• Bachelor’s degree preferred

• 5 years of PBM / health plan experience in benefits configuration, benefit testing, claims monitoring or other applicable department needs

• Medicare and government programs experience required

• Tremendous attention to detail, ability to shift priorities easily and ability to work in high paced, deadline drive environment.

• Exceptional written and verbal communication skills

• Experience working with product/dev teams and familiarity with Agile, preferred

• Preferred: experience working with structured or unstructured data in Excel, SQL, and other data visualization tools

Base Salary: $75,000 - $95,000

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 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.

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Salary : $75,000 - $95,000