Position Summary:

The Senior Manager, Government Programs Operations - Medicare is responsible for ensuring accurate adjudication of Medicare Part D prescription drug claims while maintaining compliance with CMS regulations. The ideal candidate will have extensive knowledge of Medicare Part D claims processing rules, regulatory changes to claim adjudication requirements, and industry best practice standards.

Position Responsibilities:

Claims Adjudication and analysis:

• Review, analyze, and resolve Medicare Part D claims to ensure compliance with CMS guidelines

• Investigate claim rejections, overrides, and disputes to identify root causes and coordinate corrective actions

• Monitor claims processing systems to detect anomalies, inaccuracies, or trends requiring intervention

Regulatory Compliance & Quality Assurance:

• Ensure compliance with CMS regulations and internal policies related to Medicare Part D claims processing

• Provide subject matter expertise for regulatory audits, client pre/post delegation audits, and internal quality reviews, as required

• Stay up to date on regulatory changes impacting Medicare Part D claim processing and communicate updates to stakeholders to ensure all internal systems and processes comply with current requirements

Process Improvement and System Support:

• Collaborate with IT and operations teams to optimize claims adjudication workflows and system configurations

• Identify and recommend process enhancements to improve efficiency and accuracy in claims processing

• Work with Medicare clients, pharmacies, and internal teams to resolve escalated claim issues

• Develop and maintain documentation related to Medicare Part D claims adjudication policies and procedures

Leadership:

• Manage a team of analysts to achieve goals, fostering a positive and productive work environment.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• 6+ years of experience in Medicare Part D claims processing within a PBM

• Extensive knowledge of CMS regulations, Medicare Part D benefit designs, and claims adjudication processes

• Ability to operationally interpret and apply Medicare Part D regulations and guidance effectively

• Strong analytical and problem-solving skills, with attention to detail

• PDE (Prescription Drug Event) reporting and reconciliation subject matter expertise preferred

• Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables

• Experience successfully managing a team of direct reports