Medicare & Medicaid Operations & R&R Specialist

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

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