Capital Rx

QA Engineer

• Perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of Medicare coverage requests and appeals
• Complete monthly coverage determination, organization determination, and appeals performance and process audits in alignment with CMS regulations and best practices
• Create and maintain progress reports and audit results in accordance with regulatory requirements and internal processes
• Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory requirements (CMS, URAC, NCQA)
• Continuously review and remain informed of all CMS regulatory requirements and updates impacting the coverage request and appeals processes
• Respond to inquiries from internal and external stakeholders regarding quality assurance processes, audit results, and compliance policies and procedures
• Work independently and with team members as warranted by audit assignment
• Assist in designing and implementing audit tools and programs, creating QA scorecards and guides in collaboration with all department stakeholders
• Provide ongoing performance feedback to team leads to ensure consistent performance
• Assist management in identifying, evaluating, and mitigating operational and compliance risks
• Work in collaboration with operational leaders to identify training opportunities and recommend improvements to Work Instructions, Job Aids, and Policy and Procedures to improve performance

Quality Assurance Pharmacist – Medicare

Manager

• Lead project management and delivery of print and digital member communications, including build, development, and QA testing.
• Oversee approvals of member communications through the external print vendor platform, ensuring adherence to timelines and quality standards.
• Cultivate and maintain relationships with print vendors, focusing on improving process efficiencies and serving as a liaison between teams to foster collaboration.
• Track, analyze, and report on print requirements and fulfillment to identify areas for improvement and enhance operational efficiency.
• Manage communication workflows and approval processes to ensure timely and accurate deliverables that meet member expectations.
• Collaborate cross-functionally with multiple internal and external teams to provide oversight on project success and timely delivery of member communication deliverables.
• Serve as a subject matter expert during new client implementations, ensuring seamless integration of communication strategies that align with client expectations.
• Mentor and train communication team members on internal processes and best practices, ensuring consistency and effectiveness across the team’s deliverables.
• Provide training and support to other departments as needed to ensure alignment with communication protocols and strategies for member engagement.
• Ensure all communications comply with regulatory requirements and industry standards while amplifying the member experience.
• Continuously evaluate and improve existing communication strategies to enhance clarity, effectiveness, and member engagement.
• Manage ad-hoc communication requests efficiently, prioritizing based on organizational needs and member impact.
• Support client management and business development efforts as required to enhance member experience and organizational growth.
• Facilitate an environment of collaboration and innovation within the team, promoting engagement and professional development.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Member Experience Manager

IT Support

• Capital Rx: health technology company and PBM providing claim administration and cloud-native enterprise health platform Judi.
• Ensure Capital Rx meets contractual and regulatory obligations to health plan clients through delegation audits.
• Manage end-to-end audit lifecycle: intake, task assignments, timelines, document tracking, status updates, and final submission.
• Coordinate and draft responses aligned with CMS, URAC, NCQA, and state-level standards.
• Lead cross-functional audit response meetings and ensure stakeholder accountability.
• Maintain audit response trackers, document repositories, and response templates.
• Partner with Legal, Compliance, Operations, and Client Success to obtain materials, attestations, and policy documentation.
• Provide guidance to client-facing teams on delegation audit protocols and expectations.
• Implement centralized audit dashboard and develop risk scoring for delegation entities.
• Track response times and completion rates; monitor audit outcomes and client feedback to inform improvements.
• Align delegation audit activities with compliance monitoring including CAP tracking and risk assessments.
• Develop monthly and quarterly audit performance reports; contribute to audit readiness and internal mock audits.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Delegation Audit Specialist

Program Manager

• 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.

Senior Manager, Government Program Operations

Operations

• Provide high-quality administrative and communications support
• Prepare reports, memos, and various internal & external deliverables
• Support accounting / finance with management of regular payables and receivables, employee expenses, etc.
• Maintain an organized filing system for all paper and electronic documents
• Serving as a point of coordination for Hours Banking and Eligibility identification and issue resolution with internal teams and external integration partners
• Identify and triage Hours Banking and Eligibility issues and support the resolution of all errors
• Proactively monitoring system status to quickly identify potential abnormalities that might impact quality and accuracy
• Ensuring that all issues and errors are resolved using designated operating standards and within defined service levels
• Assist with the validation of operational integrity through regular audits and reconciliation processes
• Participate in projects that impacts including vendor changes, client migrations, and client add-on requests
• Support ongoing management of Company policies and procedures
• Support general business needs, as required
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Operations Analyst – Hours Banking & Eligibility

Administration

• Evaluate rebate performance and perform client-level and book-of-business reconciliation analyses
• Support client-level rebate payment and reporting processes
• Continually develop and maintain rebate reporting infrastructure
• Perform analysis of current and prospective vendor partnerships
• Collaborate with other business functions (clinical, underwriting, finance, legal) to design, refine, and maintain internal reporting, modeling, and SOPs
• Support general business needs, as required

Quality Assurance Pharmacist – Medicare

Member Experience Manager

Delegation Audit Specialist

Senior Manager, Government Program Operations

Operations Analyst – Hours Banking & Eligibility

Senior Analyst, Rebate Administration