Capital Rx

Pharmacist

• Responsible for the design, configuration, and quality assurance of prior authorization (PA) criteria
• Ensures clinical intent is accurately translated into compliant, efficient system logic through structured QA/QC and validation processes
• Collaborates with internal teams and external clients to support delegated PA services and drive system optimization
• Build decision trees and question sets from PA criteria for prior authorization review
• Perform comprehensive quality control (QC) review of decision trees, questionnaires, and authorization logic to ensure alignment with clinical intent, regulatory requirements, and business rules
• Conduct quality assurance (QA) validation of configured criteria and decision paths
• Ensure PA questionnaires are configured with the appropriate authorization parameters for approval
• Collaborate with external clients for delegated clinical PA systems services
• Manage setup, contracting, and relationships with prior authorization external vendors
• Mapping of prior authorization member and prescriber letter templates in the prior authorization system
• Validate that denial rationales, approval language, and conditional messaging accurately reflect clinical criteria and system outputs
• Creation and maintenance of Commercial and Government denial verbiage templates
• Develops and maintains policies and procedures for creation and maintenance of clinical criteria questions and letter templates
• Establish and maintain QA/QC standards, documentation, and audit processes for decision trees, criteria configurations, and letter templates
• Identify PA reporting needs and collaborating with appropriate stakeholders to develop reports
• Respond to requests for clinical criteria from members and prescribers
• Attend formulary meetings and presentations

Prior Authorization Systems Pharmacist

Technician

• Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity.
• Work with appeals team for multiple lines of business such as Commercial, Exchange and Medicare, ensuring the proper submission of appeals for review by pharmacist and medical directors.
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Review all cases received, to verify if case meets qualifications for appeal review.
• Performs triple check to ensure quality reviews and handling in accordance with policies and procedures.
• Updates case types, sends appeal acknowledgements, and submits case information to independent review organizations.
• Communicate effectively with appeal pharmacists regarding internal and external appeals.
• Make verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call.
• Exhibit excellent phone and communication skills while providing complete and accurate information to members and providers.
• Performs all other related duties as assigned

Appeals Technician – Temp-to-Hire

Customer Support

• Act as the primary point of contact for incoming member calls, prior authorization inquiries, and ensure appropriate escalation of cases and all intake notes to the Clinical Prior Authorization Team
• Actively intake a thorough and complete prior authorization request from prescribers and members by asking applicable drug and client-specific clinical questions
• Accurately advise callers on options for exception requests (formulary, copay, early refill, etc.) based on client benefit elections and provide additional information and status updates to prescribers, members, and pharmacies
• Efficiently triage incoming calls with professional phone etiquette from members, prescribers, and pharmacies with minimal support. Ask probing questions to identify and resolve all issues and address concerns promptly
• Act as a valuable resource for Customer Service Representatives supporting member and pharmacy inquiries, stepping in as needed based on demand. Proactively identify, document, and address member and pharmacy concerns to ensure everyone receives the care and attention they deserve
• Effectively communicate issues and solutions to members, pharmacies, and relevant internal stakeholders to ensure customers receive quality care and that the resolution meets all health and safety standards
• Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast-paced environment
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies
• Assist with onboarding and training of new team members or temporary staff as needed
• Support the Fraud, Waste, and Abuse program by reviewing pharmacy claims information and communicating findings to appropriate internal staff
• Collaborate across different systems while utilizing up to two monitors, efficiently multitasking in a dynamic and fast-paced environment
• Self-starter who displays a positive attitude, strong work ethic, and excellent attendance
• Meet all departmental goals including schedule adherence, attendance, and quality monitoring
• Standard hours for training: Monday thru Friday, 9:00 am – 5:30 pm, Eastern
• Perform other customer support duties as assigned
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance

Customer Care Pharmacy Technician – Full-Time

General

• Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines
• Make outbound calls to providers to obtain additional clinical information to ensure substantial clinical information exists to reach a clinical determination for pharmacist review
• Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.
• Review and analyze pharmacy claims data for proactive outreach and intervention.
• Identify, document, and escalate provider concerns to the appropriate internal team including various members of the Prior Authorization Team
• Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.
• Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies
• Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast paced, startup environment

Utilization Management Technician – Temp-to-Hire

• Responsible for overseeing a group of prior authorization technicians and expanded responsibility for select administrative PA functions.
• Work in conjunction with the pharmacy technician manager in analyzing available data and provide prior authorization staffing, workflow and system enhancement recommendations.
• Support on-going training and coaching of utilization management pharmacy technicians.
• Participate in the goal setting process and regularly review performance of direct reports, addressing performance and behavioral issues when needed.
• Investigate/resolve escalated issues or problems from clients and providers.
• Works with utilization management manager on other responsibilities, projects, implementations and initiatives as needed.
• Review pharmacy claims data for proactive outreach and intervention.
• Maintain quality and productivity standards for all cases triaged while minimizing compliance risk.
• Work with business and clinical partners as needed.
• Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines.
• Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review.
• Identify, document, and escalate provider concerns to the appropriate internal team including various members of the utilization management team.
• Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions.
• Effectively communicate issues and resolutions to members, pharmacy staff, providers, and appropriate internal stakeholders.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies.
• Ensure customer satisfaction, extraordinary customer care, and quality resolution with genuine compassion in a fast paced, startup environment.
• Ability to work in a fast-paced environment with shifting priorities, and flexible schedules that may include weekends.
• Ability to work flexible schedules that includes an on-call weekend and holiday rotation.

Supervisor, Utilization Management Technician

Utilization Management Appeals Technician – Temp-to-Hire

Account Manager

• Support implementation and client management teams with all day-to-day client requirements
• Responsible for timely and accurate management and execution of all client benefit requests, including benefit changes, eligibility changes, and new implementations
• Analyze incoming client requests and work with internal and external teams to complete required plan documentation
• Support implementation of new plans, pricing, and networks, consistent with strategic or administrative intent
• Lead pre- and post-implementation quality assurance and testing to validate coding accuracy
• Lead claim reviews to proactively identify discrepancies or inaccuracies and develop solutions to address
• Handle and resolve sponsor and member issues, escalating as needed
• Research and respond to claims processing and system configuration inquiries
• Coordinate integration of other data inputs into client management processes
• Collaborate cross functionally to support general client operations, as required

Account Coordinator

Business Analyst

• Continuously monitor federal and state regulatory sources (e.g., CMS, state Medicaid agencies, HHS) for new or revised requirements
• Analyze proposed and final rules, guidance, and policy updates to determine applicability and business impact
• Summarize complex regulatory changes into clear, actionable insights for internal stakeholders
• Conduct impact assessments across business functions including operations, compliance, network, clinical, and technology
• Partner with subject matter experts to define business requirements and implementation plans
• Support prioritization of regulatory initiatives based on risk, complexity, and deadlines
• Facilitate working groups and stakeholder meetings to drive alignment on regulatory changes
• Track progress of implementation activities and ensure accountability across teams
• Act as a central liaison between legal, operations, and clinical leadership
• Maintain a centralized inventory of regulatory changes and implementation status
• Develop executive-level summaries, dashboards, and status reports
• Ensure documentation meets audit and compliance standards
• Partner with Compliance to ensure adherence to regulatory requirements
• Identify risks, gaps, and dependencies associated with regulatory changes
• Support audit readiness and remediation efforts as needed
• Investigate regulatory-related defects and/or client compliance concerns and develop root cause analyses when necessary.
• Enhance regulatory change management processes, tools, and governance frameworks
• Drive standardization and efficiency in how regulatory changes are tracked and implemented
• Recommend automation or workflow improvements where applicable
• Support client or government led audits as a regulatory compliance expert through:
• Research and analysis
• Documentation and as a speaker
• Workflow and Judi navigator

Regulatory Change Management Analyst

QA Engineer

• Collaborate with leadership to develop and maintain customer care quality scorecards
• Conduct quality evaluations of recorded and live customer interactions
• Assess agent adherence to procedures and compliance procedures
• Facilitate and participate in calibration sessions
• Support Customer Satisfaction (CSAT) calibration efforts
• Analyze QA data and reporting to identify trends
• Provide performance reporting and support to supervisors
• Identify training needs through QA evaluations
• Oversee the end-to-end processing of member complaints and grievances
• Review, document, and research Authorized Representative (AOR) forms
• Ensure timely and accurate completion of QA reporting
• Handle inbound or outbound calls as needed
• Report any compliance concerns or policy violations

Quality Assurance Analyst – Customer Care

Program Manager

• Oversee the implementation, compliance, and optimization of Medicare, Medicaid, and Exchange programs
• Lead a team dedicated to identifying, developing, and maintaining technical analysis and efficiencies
• Design automated solutions and validate accuracy of outgoing deliverables
• Establish scalable processes that support regulatory and business objectives
• Interpret CMS and state guidance
• Collaborate with internal subject matter experts and clients
• Analyze complex datasets to identify trends and process improvements
• Create detailed specifications for reports and operational tools
• Collaborate with cross-functional teams to enhance operational capabilities

Government Program Operations Manager – Analysis, Efficiencies

Sales

• Build and execute a national go-to-market plan to win net-new logos for the Judi platform
• Create pipeline through targeted outreach, your network, and disciplined account planning—then qualify opportunities quickly and honestly
• Run discovery that gets to the real buying drivers (configuration speed, flexibility, vendor consolidation, total cost) and maps stakeholders, timelines, and risks
• Lead product demos and storytelling that translate complex platform capabilities into clear business value for health plan/TPA executives and operators
• Own RFI/RFP strategy and responses in partnership with internal teams—ensuring submissions are accurate, compelling, and tailored to the prospect
• Manage commercial strategy end-to-end: scoping, pricing approach, security/compliance inputs, contract negotiation, and close
• Partner closely with Implementation and Product to set prospects up for successful delivery and long-term growth post-signature
• Maintain clean pipeline hygiene and forecasting in Salesforce, with clear next steps and executive-level updates
• Bring market feedback back to the business—what our prospects are asking for, competitive dynamics, and where we should invest to win more deals

VP, SaaS Sales

Client Services Representative

• Responsible for the overall satisfaction and retention of large enterprise employer commercial client(s) book of business
• Serve as the relationship owner on assigned book of business, incorporating internal support where and when as needed to foster relationships with C-suite, influencers, and decision makers at the plan
• Develop strategy plans, with support of clinical account consultant and account manager
• Support member and client satisfaction execution and net promoter score goals
• Provide deep and approachable plan recommendations with support of reporting and internal stakeholders
• Maintain thorough knowledge of contractual obligations assigned book of business, including financials, performance guarantees, terms, and regulatory/compliance
• Lead the account team in managing client vendor relationships as appropriate
• Lead client renewal process, including contract management
• Lead ownership of performance guarantee reporting and maintenance
• Lead regulatory and compliance components Interpret current pharmacy and healthcare trends, and meet with clients to provide proactive recommendations for plan management; find ways of adding value to the client curating offerings tailored to the client’s specific needs
• Identify and contribute to process improvement efforts across Capital Rx
• Assemble internal resources to overcomes challenges
• Anticipates customer needs and proactively identifies new opportunities within assigned accounts
• Develop a comprehensive knowledge of our business, including products and services. Strong ability to field questions from the client side, answer them and answer them correctly
• Review and advise on JUDI product roadmap to ensure current priorities and milestones will meet the client expectation

Account Executive, PBA Enterprise Client Services

Analyst

• Lead analytics projects, collaborating with business stakeholders to develop and deliver reporting solutions and actionable insights.
• Produce strategic insights on program performance, compliance, utilization trends, and financial projections.
• Ensure data integrity by developing and maintaining clear documentation of query logic, methodologies, and key assumptions.
• Work cross-functionally with internal teams to align analytical insights with business objectives, regulatory requirements, and financial considerations.
• Interpret current pharmacy and healthcare trends, and meet with clients to provide proactive recommendations for plan management; find ways of adding value to the client curating offerings tailored to the client’s specific needs.
• Apply expertise in data analytics to identify opportunities for process optimization, automation, and improved reporting methodologies.

Senior Analyst, Analytics – Business Insights

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
• Perform and handle inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations.
• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria.
• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.
• Perform peer to peer reviews with providers when requested.
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Appeals Pharmacist – Temp-to-Hire

Product Manager

• Collaborate with other PMs, engineers, UX designers, and other stakeholders to ensure on-time delivery of product features.
• Effectively manage and meet stakeholders’ priorities and expectations while assuming the role of a subject matter expert through deep intellectual curiosity and drive to learn.
• Partner with go-to-market and client-facing teams to identify key value-add opportunities.
• Drive the development of standardized and scalable data models.
• Analyze product data to derive insights to assist in the prioritization and post release optimization of the products.
• Translate business, analytics, and operational needs into a prioritized roadmap for the Enterprise Data Warehouse.
• Work with design team to conduct user experience testing and research.
• Collect and act on feedback from internal stakeholders and external clients to ideate and anticipate new products.
• Create and maintain team specific 15 month rolling product roadmap.
• Develop business requirements and specification documents.
• Perform backlog refinement, epic planning, and other scrum events.
• Conduct user testing prior to and post release of functionality to the customer.
• Publish value driven release notes and user guides.
• Present roadmap updates and product delivery risks to senior leadership.
• Manage and execute day-to-day project management functions with regards to the specific products under development.
• Support general business needs, as required.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.