Medicare Part D Programs Leader

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 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