Product Manager, Claim Adjudication (GP)

Navitus

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other._____________________________________________________________________________________________________________________________________________________________________________________________________________. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities. ____________________________________________________We are committed to providing equal employment opportunity to all applicants and employees and comply with all applicable nondiscrimination regulations, including those related to protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or handicap.

USD $82,586.00 - USD $101,333.00 /Yr.

5.00 - Salaried Non-Management except pharmacists

M-F 8am to 5pm CT

ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Due to growth, we are adding a Claims Adjudication Product Manager (CAPM) to our team.

 

The Claims Adjudication Product Manager (CAPM) is responsible for ensuring Med D, Medicaid, and Exchange claims are adjudicating per CMS regulations as well as specific client needs. The CAPM will collaborate with other Navitus teams to ensure that the appropriate software, procedures, and oversight monitoring are implemented and operational in support of an environment of continuous improvements with claims adjudication.

 

Is this you? Find out more below!

How do I make an impact on my team? 

• Champion and maintain a proactive internal audit process to verify claims are adjudicating as expected. Conduct root cause analysis to minimize future defects
• When adjudication issues are discovered, champion root cause analysis efforts of these issues in support of continually lowering our adjudication Defects per Million opportunities
• Work closely with Recoveries Product Manager to verify recoveries projects produce the expected results as well as to improve the overall accuracy of the adjudication process
• Oversee all adjudication-related fixes/enhancements. This includes oversight of system requirements development, and testing
• Ensure post-implementation monitoring processes are in place to validate adjudication-related fixes/enhancements are working as expected
• Serve as subject matter expert for claims adjudication-related questions and system enhancements
• Oversee timely completion of Acumen audit responses and leverage these results to improve claim adjudication accuracy
• Ensure metrics are monitored and reported
• Create and maintain claim adjudication training resources
• Other duties as assigned

What our team expects from you?

• College degree or equivalent experience required in managed care or health insurance
• Minimum of two years’ experience with Medicare claims adjudication preferred
• Has successfully lead root cause analysis projects
• Project Management and/or Business Analyst experience a plus
• Data analysis experience a plus
• On-call availability
• Some travel may be required
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

#LI-Remote

 

Remote

US