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About the Role
The Government Programs Operations Analyst supports operational functions across Medicare, Medicaid, Exchange, and Commercial lines of business, serving as the Reprocessing & Reversals (R&R) subject matter expert. This role executes and validates R&R activities, provides guidance, and collaborates with Product and Development teams on system and process enhancements. The Analyst applies expertise in regulatory compliance and claims operations to resolve issues, maintain documentation, and improve operational integrity, efficiency, and scalability.
Responsibilities
- Serve as the primary Reprocessing & Reversals (R&R) subject matter expert, executing R&R activities and supporting continuous process improvement across applicable lines of business.
- Run and validate R&R activities, including complex claim reversals, reprocessing, retroactive changes, coordination-of-benefits adjustments, and other regulatory- or client-driven corrections.
- Partner with Product and Development teams to define R&R business requirements, evaluate proposed solutions, prioritize enhancements, and ensure functionality supports operational, regulatory, and client needs.
- Perform operational testing and validation of R&R enhancements, document outcomes and defects, and coordinate with Product and Development through implementation and post-production monitoring.
- Establish and maintain R&R procedures, controls, documentation, standard operating procedures, and audit-ready evidence to support consistent and compliant execution.
- Provide R&R guidance, training, and issue support to Operations, Client Services, Product, Development, and other internal stakeholders.
- Conduct root cause analysis of R&R and claims-processing issues, identify systemic trends, and implement corrective and preventive actions in collaboration with cross-functional partners.
- Perform day-to-day operational tasks related to claims processes, including PDE, Medicare Plan Finder, and Encounter Data submissions, while assessing downstream impacts of R&R activities.
- Support error handling and change management for PDE and encounter submissions, ensuring R&R outcomes align with CMS, state, and client requirements.
- Stay current on CMS guidance and regulatory updates, translating changes into actionable operational strategies.
- Share R&R knowledge and provide guidance to team members and cross-functional partners as needed.
- Maintain current knowledge of Medicare & Medicaid requirements to facilitate compliance of ongoing business operations.
Requirements
- 3+ years of experience in PBM or health plan operations, with experience supporting Medicare Part D, Medicaid, Exchange, and/or Commercial
- Proven subject matter expertise in pharmacy claim reprocessing and reversals, including complex claim corrections, operational controls, issue resolution, and downstream regulatory reporting impacts.
- Advanced MS Excel skills (pivot tables, complex formulas, data modeling); familiarity with SQL or other data tools is a plus.
- Demonstrated experience partnering with cross-functional teams to define business requirements, support solution design, perform user acceptance testing, manage defects, and implement operational enhancements.
- Strong analytical and problem-solving skills, with a track record of driving operational improvements.
- Strong written and verbal communication skills, with the ability to collaborate effectively with operational and technical stakeholders.
- Deep understanding of CMS compliance requirements and audit readiness.
- Highly organized, detail-oriented, and committed to delivering high-quality work.
Skills
- Reprocessing & Reversals (R&R)
- Claims Processing
- Regulatory Compliance
- MS Excel
- SQL
- Data Analysis
- Problem-Solving
- Communication
- Medicare
- Medicaid
- Exchange
- Commercial Health Plans
- PBM Operations
Location
- Hybrid (Local to NYC, Denver, CO or Charlotte, NC)
Work Type
- Hybrid
Experience Level
- 3+ years
Salary/Compensations
- $98,800—$123,500 USD (New York, NY)
- $90,800—$113,500 USD (Denver, CO)
- $82,400—$103,000 USD (Charlotte, NC)
About the Company
- 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.
Equal Opportunity
- 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.