Delegation Audit Specialist
Capital Rx
Cloud
Senior Manager, Government Program Operations
Capital Rx
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $120,000 - $135,000 per year
Job Level
Senior
Tech Stack
Cloud
About the role
- Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities.
- Ensure accurate adjudication of Medicare Part D prescription drug claims while maintaining compliance with CMS regulations.
- Review, analyze, and resolve Medicare Part D claims; investigate rejections, overrides, and disputes to identify root causes and coordinate corrective actions.
- Monitor claims processing systems to detect anomalies, inaccuracies, or trends requiring intervention.
- Provide subject matter expertise for regulatory audits, client pre/post delegation audits, and internal quality reviews.
- Collaborate with IT and operations teams to optimize claims adjudication workflows and system configurations.
- Identify and recommend process enhancements to improve efficiency and accuracy; develop and maintain Medicare Part D adjudication documentation.
- Manage a team of analysts, foster a positive work environment, and ensure adherence to the Capital Rx Code of Conduct.
Requirements
- 6+ years of experience in Medicare Part D claims processing within a PBM
- Extensive knowledge of CMS regulations, Medicare Part D benefit designs, and claims adjudication processes
- Ability to operationally interpret and apply Medicare Part D regulations and guidance effectively
- Strong analytical and problem-solving skills, with attention to detail
- PDE (Prescription Drug Event) reporting and reconciliation subject matter expertise preferred
- Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables
- Experience successfully managing a team of direct reports
