Government Programs Operations Analyst - R&R

Capital Rx Inc.; New York (NY); Hybrid; USD 99,000 - 124,000; Full time

Job summary

The Government Programs Operations Analyst at Judi Health supports Medicare, Medicaid, Exchange, and Commercial lines, serving as the Reprocessing & Reversals SME. The role executes and validates R&R activities, providing guidance and coordinating with Product and Development to implement system and process enhancements.

Ideal candidates have 3+ years in PBM or health plan operations, strong Excel (Pivot) skills, SQL familiarity, and a proven ability to collaborate with cross-functional teams to

Qualifications

• 3+ years in PBM or health plan operations.
• Subject matter expert in pharmacy claim reprocessing and reversals.
• Advanced Excel skills with pivot tables and formulas; SQL familiarity a plus.
• Experience partnering with cross-functional teams to define requirements and support solution design.
• Strong analytical and problem-solving abilities with a track record of improvements.
• Excellent written and verbal communication skills.
• Deep CMS compliance knowledge and audit readiness.
• Highly organized and detail-oriented.

Responsibilities

• Serve as the primary R&R SME and drive continuous process improvements across applicable lines of business.
• Run and validate R&R activities, including complex reversals, reprocessing, retroactive changes, CB adjustments, and client-driven corrections.
• Partner with Product and Development to define R&R requirements, evaluate solutions, prioritize enhancements, and ensure regulatory and client needs are met.
• Perform operational testing and validation of R&R enhancements, document outcomes, and coordinate implementation and post-production monitoring.
• Establish and maintain R&R procedures, controls, documentation, SOPs, and audit-ready evidence.
• Provide R&R guidance, training, and issue support to Operations, Client Services, Product, Development, and other stakeholders.
• Conduct root cause analysis of R&R and claims issues, identifying trends and implementing corrective actions.
• Handle PDE, Medicare Plan Finder, and Encounter Data submissions, assessing downstream impacts.
• Support error handling and change management for PDE and encounter submissions to align with CMS and client requirements.
• Stay current on CMS guidance and translate changes into operational strategies.
• Share R&R knowledge with team and cross-functional partners.
• Maintain knowledge of Medicare and Medicaid requirements.

Skills

Excel pivot

SQL familiarity

Cross-functional collaboration

Analytical skills

Communication skills

CMS compliance

Detail orientation

Tools

MS SQL

Job description

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.

At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health

Location: Hybrid (Local to NYC, Denver, CO or Charlotte, NC)

Position Summary:

The Government Programs Operations Analyst supports operational functions across Medicare, Medicaid, Exchange, and Commercial lines of business, with the primary responsibility of serving as the Reprocessing & Reversals (R&R) subject matter expert. The Analyst executes and validates R&R activities, provides operational and regulatory guidance, and works closely with Product and Development teams to design, test, and implement system and process enhancements. This role applies expertise in regulatory compliance and claims operations to resolve issues, maintain accurate documentation, and improve the integrity, efficiency, and scalability of operations.

Position Responsibilities:

• Serve as the primary Reprocessing & Reversals (R&R) subject matter expert, executing R&R activities and supporting continuous process improvement across applicable lines of business.
• Run and validate R&R activities, including complex claim reversals, reprocessing, retroactive changes, coordination-of-benefits adjustments, and other regulatory- or client-driven corrections.
• Partner with Product and Development teams to define R&R business requirements, evaluate proposed solutions, prioritize enhancements, and ensure functionality supports operational, regulatory, and client needs.
• Perform operational testing and validation of R&R enhancements, document outcomes and defects, and coordinate with Product and Development through implementation and post-production monitoring.
• Establish and maintain R&R procedures, controls, documentation, standard operating procedures, and audit-ready evidence to support consistent and compliant execution.
• Provide R&R guidance, training, and issue support to Operations, Client Services, Product, Development, and other internal stakeholders.
• Conduct root cause analysis of R&R and claims-processing issues, identify systemic trends, and implement corrective and preventive actions in collaboration with cross-functional partners.
• Perform day-to-day operational tasks related to claims processes, including PDE, Medicare Plan Finder, and Encounter Data submissions, while assessing downstream impacts of R&R activities.
• Support error handling and change management for PDE and encounter submissions, ensuring R&R outcomes align with CMS, state, and client requirements.
• Stay current on CMS guidance and regulatory updates, translating changes into actionable operational strategies.
• Share R&R knowledge and provide guidance to team members and cross-functional partners as needed.
• Maintain current knowledge of Medicare & Medicaid requirements to facilitate compliance of ongoing business operations.

Required Qualifications:

• 3+ years of experience in PBM or health plan operations, with experience supporting Medicare Part D, Medicaid, Exchange, and/or Commercial
• Proven subject matter expertise in pharmacy claim reprocessing and reversals, including complex claim corrections, operational controls, issue resolution, and downstream regulatory reporting impacts.
• Advanced MS Excel skills (pivot tables, complex formulas, data modeling); familiarity with SQL or other data tools is a plus.
• Demonstrated experience partnering with cross-functional teams to define business requirements, support solution design, perform user acceptance testing, manage defects, and implement operational enhancements.
• Strong analytical and problem-solving skills, with a track record of driving operational improvements.
• Strong written and verbal communication skills, with the ability to collaborate effectively with operational and technical stakeholders.
• Deep understanding of CMS compliance requirements and audit readiness.
• Highly organized, detail-oriented, and committed to delivering high-quality work.

New York, NY Salary Range

$98,800 — $123,500 USD

Denver, CO Salary Range

$90,800 — $113,500 USD

Charlotte, NC Salary Range

$82,400 — $103,000 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We 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.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found athttps://www.judi.health/legal/privacy-policy.