Manager, Government Programs (EGWP)

Transformcap; United States; Hybrid; USD 107,000 - 160,000; Full time

Job summary

Judi Health in New York is seeking a Government Programs EGWP Manager to lead regulatory compliance for the Health Plan EGWP line, driving implementation, daily oversight and change management of CMS requirements. You will oversee claims processing, CDAG, audits and delegate partnerships to meet financial and service objectives.

The role requires deep Medicare Part D knowledge, strong operational acumen, and collaboration with internal teams and external stakeholders to ensure timely regulatory

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, 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.

Skills

Medicare Part D knowledge

EGWP experience

Operational acumen

CMS reporting

Education

HS diploma/GED or equivalent experience

Tools

HPMS

MARx

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 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

Salary Ranges

• 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 match 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 at https://www.judi.health/legal/privacy-policy.