TPA Operations Supervisor

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,
• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.

Position Summary:

Join our Judi Health TPA team as a TPA Operations Supervisor, where you will play a pivotal role in delivering comprehensive medical, dental, and vision support to parties of our TPA team. You will lead in overseeing daily operations of our TPA, including areas such as appeals, correspondence, training, and more. This position offers the opportunity to influence operational best practices and contribute to a team that is redefining operational excellence in the healthcare space.

Position Responsibilities:

• Drives cross-functional collaboration with the product/dev team as well as additional stakeholder teams to ensure enhancements to Judi drive operational efficiency and support on-going client needs
• Manage incoming correspondence via multiple workstreams (fax, e-mail, mail)
• Analyze and respond to 1st level appeals within timeframe required by law
• Provide daily support to our award-winning Customer Care team, including assisting with and delegating escalations
• Make recommendations to streamline the work processes and systems that daily operations to create efficiency and quality outcomes
• Provide support to the medical Claims Department, including handling and delegating escalated issues and serving as an SME resource for the Judi system and claims processing
• Identify, troubleshoot, and escalate any operational discrepancies immediately to avoid care disruption
• Develop standard policies and procedures, training materials, and provide ongoing education and training to internal or external cross-functional teams
• Track and maintain acceptable and appropriate quality levels and production SLA response times
• Partner with internal teams as clients go live and troubleshoot operational discrepancies, errors, and problems
• Support general business or team needs, as assigned
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum Qualifications:

• Bachelor’s degree preferred
• 5+ years of TPA / health plan experience in Claims Adjudication, Appeals, Plan Design, or other applicable department needs
• Ability to interpret multiple client plan designs and SPDs
• Enhanced knowledge of CPT, HCPCs, ICD-10, CDT coding a plus
• 3+ years of experience with Cigna Payer Solutions a plus
• Pharmacy, Dental, or Vision experience a plus
• Self-funded plans, Medicare/Government programs and ERISA experience preferred
• Tremendous attention to detail, ability to shift priorities easily and ability to work in a high paced, deadline drive environment.
• Exceptional written and verbal communication skills
• Experience in No Surprise Act Open Negotiation Appeals a plus

All employees are responsible for adherence to the Capital Rx 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.

Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to 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 at https://www.judi.health/legal/privacy-policy.