Capital Rx

Account Manager

• Establish and develop relationships with key client decision-makers, understand their healthcare strategy and goals, determine how Capital Rx can best help them achieve their desired results
• Provide oversight of client account management team with a focus on member and client satisfaction, trend management, and client retention
• Partner with account team members to provide best-in-class member and client service
• Support member issue resolution at client-level
• Identify and contribute to process improvement efforts within the team
• Responsible for management and execution of client contractual requirements
• Responsible for client retention including execution of contract renewals
• Analyze and interpret pharmacy claims data to identify clinical trends and insights for individual clients
• Meet with clients to discuss clinical trends, review relevant pharmacy data, and provide recommendations with supportive rationale for clinical management strategies
• Interpret current pharmacy and healthcare trends and provide proactive recommendations
• Incorporate treatment & practice guidelines, clinical education, and pharmacy pipeline details into client presentations
• Comprehend and effectively explain formulary and clinical programs to clients, including member experience
• Communicate drug information to clients and respond to plan-specific clinical inquiries
• Analyze and evaluate pharmacy benefit reporting and create ad-hoc reports as requested
• Build and manage strong relationships with third-parties who also service our clients
• Support general business needs and operations, as required
• 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 Manager – PBM

Proposal Manager

• Develop processes, procedures, and content to support the demand for Capital Rx’s services in the assigned market(s).
• Manage and iterate upon existing collateral and reference guides (i.e.. RFP standard bidding terms) for the assigned markets.
• Works collaboratively with the RFP Content Manager to develop and refine content, collateral, and templates for the assigned market(s).
• Works collaboratively with Capital Rx’s Senior Director, Underwriting, to refine processes related to the assigned market(s).
• Collaborates with Director, Proposal Development, Commercial PBM Market to ensure adequate support for respective markets.
• Supports Capital Rx’s existing health plan book of business by providing proposal development support as requested, including facilitating kick off call meetings, triaging opportunities for non-standard requirements or questions, and working collaboratively with Capital Rx’s Client Services team to support clients’ business development goals.
• Manages the health plan and public sector proposal queue while acting as an individual contributor on key/strategic RFPs.
• Collaborate with marketing to maintain complete and current materials required to deliver competitive proposals.
• Collaborate with Executive Leadership and other business functions (sales, government programs, clinical, Legal, and clients services) to design, refine, and maintain standard operating procedures.
• Track proposal success metrics, analyze KPIs, and implement continuous improvement initiatives.
• Directs and executes RFP proposal development and submission for new business opportunities in the health plan and public sector market segments.
• Coordinate with sales and manage project plans for all incoming and outstanding RFP opportunities.
• Review RFP documents and requirements; manage allocation of internal resources to support complete response.
• Coordinate with underwriting and other business functions to submit timely and complete RFP responses.
• Customize proposals based on regulatory requirements, client demographics, utilization data, and benefit design preferences.
• Provide training and mentorship to proposal development staff and cross-functional contributors on PBM-specific proposals.
• Supports broader RFP team with writing strategic responses to targeted questions that require more tailored or customized writing.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Proposal Director, Public Sector and PBA Markets

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