R&R & Claims Operations Analyst (Medicare/Medicaid)

Capital Rx Inc.; Denver (CO); Hybrid; USD 91,000 - 114,000; Full time

Job summary

Judi Health is seeking a Government Programs Operations Analyst to support Medicare, Medicaid, Exchange, and Commercial lines, focusing on Reprocessing & Reversals (R&R). The role requires expert handling of R&R activities, regulatory guidance, and collaboration with Product and Development teams to drive compliant system enhancements.

The ideal candidate will have 3+ years in PBM/health plan ops, strong Excel skills, and experience with CMS guidance, claims processing, and audit-ready

Qualifications

• 3+ years in PBM or health plan operations with Medicare/Medicaid experience.
• Subject matter expert in pharmacy claim reprocessing and reversals.
• Advanced Excel skills; SQL or data tools a plus.
• Experience defining requirements and supporting solution design.

Responsibilities

• Serve as primary R&R SME and drive process improvements.
• Run and validate R&R activities including complex reversals and corrections.
• Collaborate with Product/Development to define business requirements.
• Test and validate enhancements; document outcomes and defects.
• Maintain procedures, controls, and audit-ready evidence.
• Provide R&R guidance and training to stakeholders.
• Analyze root causes of R&R issues and implement corrective actions.
• Handle PDE, Plan Finder, and Encounter Data submissions impact assessments.
• Ensure CMS, state, and client regulatory compliance.

Skills

R&R subject matter expert

Medicare/Medicaid knowledge

Analytical thinking

Regulatory compliance

Cross-functional collaboration

Communication skills

Problem solving

CMS knowledge

Tools

Excel

SQL

Job description

Judi Health is seeking a Government Programs Operations Analyst to support Medicare, Medicaid, Exchange, and Commercial lines, focusing on Reprocessing & Reversals (R&R). The role requires expert handling of R&R activities, regulatory guidance, and collaboration with Product and Development teams to drive compliant system enhancements.

The ideal candidate will have 3+ years in PBM/health plan ops, strong Excel skills, and experience with CMS guidance, claims processing, and audit-ready