Pharmacy Formulary & Coding Specialist

Capital Rx; New York (NY); On-site; USD 70,000 - 85,000; Full time

Job summary

Judi Health in New York, NY is seeking a licensed Pharmacy Technician to support formulary maintenance and operationalize client formulary requests within our adjudication platform.

You will triage Salesforce cases, assist with claims troubleshooting, and help develop marketing materials and job aids while collaborating with cross-functional teams.

Qualifications

• Registered Pharmacy Technician license required.
• Certification from PTCB or NHA preferred.
• 3-4 years of pharmacy experience in a health plan or PBM.

Responsibilities

• Support weekly, monthly, and quarterly maintenance and QA checks of standard and custom formularies for all lines of business.
• Assist pharmacists in operationalizing client formulary and benefit requests within the formulary management and adjudication platform.
• Triages and assists with Salesforce cases for custom formularies.
• Triages and monitors the Formulary Operations inbox.
• Uploads formulary composites and supports testing by uploading adjudication data to Salesforce cases.
• Assist pharmacists with cross-functional support for claim troubleshooting via adjudication platform.

Skills

Pharmacy technician license

PBM knowledge

Excel advanced

Large dataset experience

Pharmacy claims terminology

Education

Pharmacy technician certification (PTCB/NHA)

PBM experience

Tools

Microsoft Excel

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 Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing architecture, seamlessly consolidating pharmacy and medical benefit administration on a single,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 Charlotte, NC; Denver, CO; or New York, NY area)

Position Overview

We are seeking a highly motivated Medical Coding Specialist to support the accurate configuration, testing, and maintenance of medical claims processing rules within our platform, Judi. This role requires deep knowledge of medical coding, health plan operations, and claims adjudication, as well as the ability to translate client requirements into scalable system configurations. The ideal candidate is detail-oriented, adaptable, and passionate about leveraging technology to improve healthcare administration.

Key Responsibilities

• Stay current on coding and coverage guidelines from organizations such as CMS, AMA, AAPC, USPSTF, and other regulatory bodies.


• Utilize CPT, HCPCS, ICD-10, revenue, bill type, place of service, taxonomy, specialty, and related code sets to configure claims processing logic for commercial health plans.


• Configure, test, and maintain coding rules using internal coding and testing tools.


• Translate client requirements into accurate and timely system configurations.


• Research and resolve coding-related questions and escalations from claims processors, Customer Care, Account Management, and other stakeholders.


• Conduct regular claims reviews and audits to ensure coding accuracy, consistency, and compliance.


• Partner closely with Implementation, Benefit Operations, Product, and Technology teams to support new client implementations and platform enhancements.


• Contribute to continuous improvement initiatives that enhance claims processing accuracy and operational efficiency.


• Creates and maintains documentation, job aids, and reporting to support operational effectiveness and compliance.


• Support regulatory audits, quality improvement initiatives, and RFI/RFP responses as needed.


• Develop and maintain departmental resources, including SharePoint sites and other team documentation.


• Performs other duties and responsibilities as needed.

Required Qualifications

• Bachelor's degree strongly preferred.


• AAPC Medical Coding & Billing Certification (e.g., CPC) required.


• 5+ years of experience with a health plan, payer, or third-party administrator (TPA).


• Strong understanding of CPT, ICD-10, HCPCS, Revenue Codes, Bill Type Codes, Place of Service Codes, and Taxonomy Codes.


• Medicare and Medicaid experience preferred.


• Demonstrated ability to learn and apply new technologies.


• Proven track record of meeting deadlines and delivering high-quality results.


• Excellent project management, time management, prioritization, and organizational skills.


• Ability to manage multiple priorities in a fast-paced environment.


• Proficiency with Microsoft Office Suite.


• Strong verbal, written, presentation, and interpersonal communication skills.


• Ability to collaborate effectively with cross-functional and virtual teams.

Preferred Qualifications

• Analytical mindset with strong problem-solving skills and attention to detail.


• Customer-focused approach with a passion for improving healthcare operations and driving process improvements.


• Self-starter who can work independently, lead through subject matter expertise, and effectively collaborate across cross-functional teams.


• Experience supporting regulatory audits, developing operational processes, and training or onboarding team members.

This role offers the opportunity to play a key part in ensuring accurate claims processing, supporting client implementations, and helping drive innovation within a growing healthcare technology organization.

New York, NY Salary Range

$70,000—$85,000 USD

Denver, CO Salary Range

$70,000—$85,000 USD

Charlotte, NC Salary Range

$70,000—$85,000 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.