Capital Rx

Project Manager

• Manage concurrent client audits or team projects, coordinating with internal and external stakeholders to ensure on‑time, on‑scope delivery.
• Develop, maintain, and execute detailed project plans, including scope, timelines, milestones, resource allocation, and task assignments.
• Drive end‑to‑end project execution from initiation through closeout.
• Serve as the primary point of contact in external auditor and consultant meetings.
• Monitor project progress and performance, proactively managing risks, issues, and scope changes.
• Collaborate closely with cross‑functional subject matter experts to gather deliverables and ensure follow‑ups are owned and closed.
• Maintain clear communication through status updates and presentations for stakeholders and leadership.
• Build and maintain strategic relationships with external consultants, auditors, and internal teams.
• Ensure quality, compliance, and governance by maintaining complete project documentation.

Project Manager, Client Audit and Performance

Customer Support

• Efficiently triage incoming phone calls with professional phone etiquette from members and pharmacies with minimal support. Ask probing questions to identify and resolve all issues and address concerns promptly
• Provide support for call center staff, including other technicians and customer service representatives
• Identify, accurately document, and escalate member and pharmacy concerns to the appropriate internal team including various members of the Operations Team
• 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
• Communicate effectively with internal and external customers to provide first-call resolution and de-escalate customer concerns
• 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
• Support the Fraud, Waste, and Abuse program by reviewing pharmacy claims information and communicating findings to appropriate internal staff
• Work with multiple systems, up to 2 monitors, and multitask in a 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, 9:00am – 5:30pm, Eastern
• Perform other customer support duties as assigned
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Customer Care Representative

Analyst

• Research and analyze pharmacy claims to ensure accuracy and contractual compliance across benefit setup, pricing, and guarantees
• Perform audit risk assessments, annual logic reviews and ongoing monitoring activities
• Analyze, reconcile and validate large datasets across multiple internal systems; develop and maintain SQL/Python queries for audit reporting and performance monitoring
• Create audit deliverable reporting, quantify financial impact of potential and confirmed audit findings, and build dashboards to identify trends and risks
• Identify and implement automation and process improvements across audit, reporting, and reconciliation workflows
• Maintain and enhance code, reporting tools, and dashboards to improve reliability, efficiency, and scalability
• Define and document technical requirements, data specifications, and methodologies to support transparency and repeatability
• Collaborate with internal and technology teams to improve data quality, workflows, and controls
• Provide ad-hoc analysis to support evolving business and audit needs
• Responsible for the adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Client Audit and Performance Analyst

Customer Success Manager

• Provide subject matter expertise support on Judi’s function and reporting capabilities related to prior authorization
• Take accountability for accurate translation of reporting requirements for Capital Rx’s customers
• Support analytics and reporting needs for the prior authorization team and related groups
• Own swift resolution and clear communication of critical reporting issues
• Present analysis results clearly
• Assist in testing of new Judi functionality to ensure enhancements are functioning as expected and accurately processing claims transactions
• Build key cross-functional relationships with other internal teams
• Provide virtual and in-person product demonstrations
• Note: Role may periodically require meeting participation, service support or other requirements outside of standard business hours

Customer Success Analyst

Consultant

• Support clinical aspects of implementation for new clients, plans, plan changes, and other clinical plan set-up requirements. This may include gathering client clinical intent and plan requirements, building/coding plans and formularies, conducting peer-review quality control, and reviewing testing and claims output.
• Actively address all clients’ clinical needs including the management and implementation of custom formularies, clinical criteria, and clinical strategies.
• Comprehend and effectively explain formulary, benefit, and clinical programs to clients, including intervention components, member and plan experience, book of business experience, and regulatory requirements as it directly pertains to clinical functions.
• Meet with clients to discuss clinical trends, review relevant pharmacy data, and provide recommendations with supportive rationale for formulary, clinical and plan management strategies.
• Analyze and interpret pharmacy claims data to identify clinical and plan trends and to offer insights for individual clients and across multiple clients.
• Communicate drug information to clients and respond to plan-specific clinical inquiries; support resolution of member-specific inquiries.
• Collaborate with cross-functional teams to support sales initiatives, requests for information (RFI), requests for proposal (RFP), and prospect presentations.
• Actively attend and contribute to sales meetings and client presentations with a focus on clinical operations and clinical account management.
• Lead key internal clinical operations initiatives and general business needs/operations, as required.
• Identify and contribute to clinical process improvement efforts.
• Certain times of year may require meeting participation, testing, claims review, or other requirements outside of standard business hours, including weekends.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Clinical Account Consultant

Risk

• Maintain accurate PG‑related data and documentation supporting reporting and visibility.
• Track PG commitments, exceptions, and approval requirements.
• Support review of contract redlines or PG‑related issues under the direction of senior team members.
• Assist with Finance-driven processes related to forecasting or accrual considerations.
• Maintain governance documentation, workflows, and tracking of PG activities.
• Support identification of trends, risks, or process improvement opportunities.

Analyst, Risk Management – Performance Guarantees

• 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

Manager

• Lead and nurture a dynamic team of clinical pharmacists and technicians dedicated to the prior authorization and appeals process.
• Create and uphold robust policies and procedures for utilization management review.
• Utilize available data to optimize prior authorization staffing and streamline workflow.
• Actively participate in goal setting and regularly evaluate the performance of the PA team.
• Respond to requests for information (RFI) and requests for proposal (RFP) regarding prior authorization processes.
• Generate and deliver comprehensive reports on prior authorization metrics to both internal and external stakeholders.
• Manage contracts with external Independent Review Organizations and clinical resource vendors
• Supervise the UM quality management process to ensure compliance with state, federal, and regulatory guidelines.
• Participates in the quality improvement committee and supports quality improvement projects as required by URAC.
• Oversee clinical criteria and decision tree creation and maintenance.
• Lead the recruitment and onboarding process for pharmacists and technicians.
• Support the training and growth of both new and existing staff members in adherence to proper procedures.
• Investigate and resolve escalated issues from clients and clinical partners as needed.
• Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed.
• Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
• Schedule requires working Monday through Friday with occasional on‑call responsibilities and the flexibility to work outside of regular business hours based on business needs.

Manager, Utilization Management – Commercial

Backend Engineer

• Exercise leadership over features from design to delivery.
• Be a partner to product, design, and quality assurance team members.
• Become a subject matter expert on your team’s products.
• Provide technical support to cross-functional team members and stakeholders.
• Expand Judi, our web-based enterprise health platform, using Python, AWS services, and other technologies.
• Work in an Agile/Scrum environment.
• Code of Conduct: Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Senior Backend Software Developer

Software Engineer

• Act as subject matter expert in our Workflow Tooling landscape. With a specific focus on Atlassian products.
• Assist partner teams in shaping their roadmap on our workflow automation platforms.
• Design and develop clean, maintainable, performant components, workflows and software.
• Identify and clean-up existing technical debt in the platform.
• Participate in the code-review and quality assurance process, provide feedback to the organization, and keep an open mind to feedback.
• Partner with our teams to create meaningful and impactful customer journeys across all associated call center systems.
• Correct production issues that impact service, revenue or fulfillment teams with a high sense of urgency.

Developer – Atlassian Process Engineering

Financial Planning and Analysis

• Review, analyze, and reconcile pharmacy claims and payments data.
• Configure vendors for payment processing in our financial system.
• Verify and ensure that all vendors possess all required credentials.
• Ensure accurate and timely processing of pharmacy, member, and provider payments and remittances.
• Collaborate with pharmacy network partners to resolve payment-related inquiries.
• Investigate and resolve payment discrepancies and variances.
• Develop and maintain strong relationships with pharmacies, providers, and reconciliation companies.
• Prepare and distribute paper or electronic (835) remittances and reports.
• Manage the reissuance of checks for voided or reprocessed payments.
• Monitor and report on key performance indicators related to payment accuracy and timeliness.
• Ensure compliance with state regulations by submitting unclaimed funds to the state.
• Participate in the development and implementation of financial policies and procedures.
• Assist in financial audits and provide documentation as needed.
• Stay up to date with industry standards and compliance requirements.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.
• Write SQL queries to retrieve specific Pharmacy files from the data warehouse as needed.
• Respond to internal and external inquiries regarding payment data, providing clear and actionable insights.

Pharmacy Financial Operations Analyst

Risk Management Analyst – Performance Guarantees

• Support intake review, issue validation, routing, and tracking of client services and cross-departmental issues, projects, and initiatives.
• Create and maintain process documentation, SOPs, and workflow maps.
• Identify manual or inefficient processes and propose improvement opportunities partnered with the Manager.
• Support light analysis such as identifying patterns, recurring issues, or workflow bottlenecks.
• Maintain trackers or dashboards providing visibility into Client Services operational activity and partner with Analytics team on broader operational dashboard needs.
• Participate in cross-functional planning, problem-solving, and readiness activities that support Client Services.

Analyst, Client Experience – Optimization

• Monitor audit intake channels and route audit requests appropriately.
• Track deliverables, timelines, and cross-functional dependencies.
• Support submission of readiness through formatting, document quality checks, and version control.
• Maintain audit artifacts, documentation, and repository organization.
• Track corrective action tasks and follow-ups.
• Support reporting and communication with internal stakeholders.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Analyst, Risk Management – Audit

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