Manager, Government Programs (EGWP)

Capital Rx; New York (NY); Hybrid; USD 128,000 - 160,000; Full time

Job summary

Judi Health is seeking a Government Programs EGWP Manager to oversee regulatory requirements for the Health Plan EGWP line and ensure CMS compliance while meeting financial objectives. This role manages daily activities and interfaces with various internal teams and external partners across multiple locations.

Responsibilities include program setup, go-live readiness, regulatory reporting, audits support, and cross-functional collaboration to ensure accurate performance metrics and

Qualifications

• Minimum of HS diploma/GED or equivalent experience.
• 5+ years of Medicare Part D and/or EGWP experience.
• Deep knowledge of Medicare Part D claim processing requirements, CDAG oversight and monitoring, and Health Plan Part D reporting.
• Experience working in a delegated and highly matrixed organization.
• Strong operational acumen.

Responsibilities

• Manage EGWP program setup, implementation and go-live readiness across assigned internal functions and delegate oversight, including claims processing and related functions.
• Provide day-to-day management to operations analyst EGWP.
• Oversee and monitor financial performance, operational KPIs and CMS compliance metrics for PBM claims, formulary, coverage determinations, appeals and grievances (CDAG).
• Manage issue resolution and corrective action completion with related, first tier and downstream entities (FDRs).
• Perform outreach as necessary on plan-to-plan activities, FIR transaction corrections and other financial transactions requiring Health Plan interventions.
• Lead regulatory reporting to ensure timely and accurate reporting from both internal and external resources as required by the Health plan, the State and CMS.
• Collaborate cross-functionally across Judi Health on employer group issues, communications and required oversight of Health Plan functions performed by employer groups and/or delegates.
• Support internal and external audits by federal and state agencies, including audit preparation, documentation, issue response and remediation tracking.
• Develop compliant documentation for operational areas to include policies, procedures, workflows and other work instructions.
• Support Health Plan team with member communications, enrollment and member services oversight, and other functions as needed.

Skills

Strong operational acumen

Deep knowledge of Medicare Part D

Experience in delegated and matrixed组织

Regulatory reporting experience

Analytical acumen

Education

HS diploma/GED

Tools

HPMS

MARx

Job description

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 achieving 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 EGWP Manager is responsible for the implementation, operational oversight and change management of regulatory requirements for the Health Plan EGWP line of business. The role will be responsible for daily management and ongoing oversight of highly vulnerable activities with the Medicare part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). This role will perform the day to day functional activities to ensure compliance with the Centers of Medicare and Medicaid (CMS) regulations while meeting employer, member and Health Plan financial objectives.

Position Responsibilities

• Manage EGWP program setup, implementation and go-live readiness across assigned internal functions and delegate oversight, which includes claims processing and associated functions, clinical programs and activities oversight, STARs and Audits.
• Provide day to day management to operations analyst EGWP
• Oversee and monitor the financial performance, operational KPIs and CMS compliance metrics for PBM claims, formulary, coverage determinations, appeals and grievances (CDAG)
• Manage issue resolution and corrective action completion with related, first tier and downstream entities (FDRs).
• Perform outreach as necessary on plan to plan activities, FIR transaction corrections and other financial transactions that may require Health Plan interventions.
• Lead regulatory reporting to ensure timely and accurate reporting from both internal and external resources as required by the Health plan, the State and CMS.
• Collaborate cross functionally across the Judi Health organization on employer group issues, communications and required oversight of Health Plan functions performed by employer groups and/or delegates.
• Support internal and external audits by federal and state agencies, including audit preparation, documentation, issue response and remediation tracking.
• Develop compliant documentation for operational areas to include policies, procedures, workflows and other work instructions.
• Support Health Plan team with member communications, enrollment and member services oversight, and other functions as needed.

Required Qualifications

• Minimum of HS diploma/GED or equivalent experience
• 5+ years of Medicare Part D and/or EGWP experience
• Deep knowledge of Medicare Part D claim processing requirements, CDAG oversight and monitoring, and Health Plan Part D reporting.
• Experience working in a delegated and highly matrixed organization.
• Strong operational acumen

Preferred Qualifications

• Health Plan Medicare Part D and/or EGWPs
• Experience working within CMS systems, including but not limited to HPMS and MARx.
• Experience with CMS, CMS Contractor and State Audits
• Strong analytical acumen

New York, NY Salary Range: $128,000 — $160,000 USD

Denver, CO Salary Range: $117,600 — $147,000 USD

Charlotte, NC Salary Range: $106,800 — $133,500 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.