Benefit Configuration Specialist

Judi Health; Denver (CO); Hybrid; USD 72,000 - 99,000; Full time

Benefits offered by this job

Health benefits

401(k) with company match

Paid time off

Job summary

Capital Rx in New York and Denver seeks a Benefit Configuration Specialist to validate pharmacy benefit plan configurations across Commercial, Medicaid, Exchange and Medicare lines, ensuring alignment with client intent and regulatory standards.

You will analyze plan designs, review documents, perform audits, and collaborate with cross‑functional teams to ensure accurate benefit adjudication and timely resolutions. Strong PBM knowledge and Excel skills are required.

Qualifications

• Bachelor’s degree or equivalent experience in a related field.
• 3–5 years in PBM, health plan ops, or benefit configuration.
• Direct Medicare Part D/MAPD experience is preferred.
• Knowledge of formulary design, tiering, utilization management, and accumulator logic.
• Ability to translate benefit design docs into test scenarios.

Responsibilities

• Execute testing and validation of pharmacy benefit plan configurations across multiple lines of business.
• Perform audits to ensure benefit setups meet client intent, regulatory requirements, and internal standards.
• Review plan design documents and formulary specs to create executable test scenarios.
• Analyze claim outputs to confirm adjudication behavior and accumulator movement.
• Document discrepancies and collaborate with the configuration team for resolution.
• Ensure compliance with federal and state regulations, including CMS guidance where applicable.
• Maintain documentation of testing results and audit findings for client reviews.
• Participate in client meetings to review scope and testing outcomes.

Skills

Analytical skills

Detail oriented

Excel proficiency

Strong communication

Client-facing experience

Education

Bachelor’s degree in Healthcare Administration or related field

Equivalent experience in PBM or health plan operations

Tools

Microsoft Excel

Job description

About Judi Health

Capital Rx, a public benefit corporation delivering full‑service pharmacy benefit management (PBM) solutions to self‑insured employers, Judi Health™, which offers full‑service health benefit management solutions to employers, TPAs, and health plans, and Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration‑related workflows in one scalable, secure platform.

Location: Remote (for non‑local) or Hybrid (Local to New York, NY or Denver, CO area)

Position Summary

The Benefit Configuration Specialist supports testing and validation of pharmacy benefit plan configurations across Commercial, Medicaid, Exchange, and Medicare lines of business, ensuring benefit plan setups align with client intent, regulatory requirements, and internal standards.

Responsibilities

• Execute end‑to‑end testing and validation of pharmacy benefit plan configurations across multiple lines of business.
• Perform detailed implementation audits to ensure benefit setups align with client intent, regulatory requirements, and internal configuration standards.
• Review and interpret plan design documents, benefit change forms, and formulary specifications to translate requirements into executable test scenarios.
• Analyze claim outputs to confirm expected adjudication behavior and accumulator movement.
• Identify, document, and communicate configuration discrepancies or defects; collaborate with the configuration team to ensure timely resolution.
• Ensure compliance with applicable federal and state regulations, including CMS guidance where applicable.
• Maintain clear documentation of testing results, audit findings, and approval signoffs.
• Participate in client‑facing meetings to review testing scope, discuss audit findings, clarify benefit intent, and provide detailed explanations of testing results.
• Partner with cross‑functional teams to ensure benefit accuracy and successful implementation.
• Contribute to process improvements that enhance testing efficiency, audit quality, and overall benefit validation standards.
• Manage multiple audits and testing initiatives simultaneously in a deadline‑driven environment.
• Adhere to the Capital Rx Code of Conduct.

Required Qualifications

• Bachelor’s degree in Healthcare Administration, Business, Information Systems, or related field (or equivalent experience).
• Minimum 3–5 years of experience in pharmacy benefit management (PBM), health plan operations, or benefit configuration.
• Direct experience supporting Medicare lines (Medicare Part D and/or MAPD).
• Understanding of Medicare benefit structures.
• Experience testing and validating pharmacy benefit configurations in Commercial, Medicaid, Exchange, and/or Medicare lines.
• Strong knowledge of formulary design, tier structures, utilization management (PA, ST, QL), and accumulator logic.
• Ability to analyze benefit design documents and translate requirements into executable test scenarios.
• Strong analytical skills with high attention to detail and accuracy.
• Proficiency in Microsoft Excel for data review, validation, and reporting.
• Strong written and verbal communication skills.
• Experience client‑facing discussions to review benefit testing outcomes and implementation readiness.

Salary

• New York, NY (hybrid): $78,800 - $98,500
• Denver, CO (hybrid): $72,000 - $90,000
• Remote: $62,400 - $90,000

Benefits

Full‑time employees receive medical, pharmacy, dental, vision, accidental injury, critical illness, hospital indemnity, and flexible spending accounts. Additional benefits include a health savings account, voluntary life and accidental death and dismemberment insurance, basic life and accidental death coverage, paid time off, sick time, holidays, short‑term and long‑term disability, employee assistance and wellness programs, and a 401(k) plan with company match after one year.

Equal Opportunity Statement

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. All employees are responsible for adherence to the Capital Rx Code of Conduct, including reporting of non‑compliance.