Claims Adjudication Associate

requirements, business risk, and client impact. Build and maintain trusted relationships with stakeholders by advising on claims-adjudication processes, communicating recommendations, and supporting resolution of complex or sensitive claim matters. Provide guidance during implementations and client support activities regarding adjudication infrastructure, processing workflows, reporting, inquiry management, and complex claim scenarios. Identify execution risks, operational gaps, and compliance or client-impact issues; develop mitigation strategies; and recommend or implement process improvements that support automation, quality, efficiency, and risk reduction. Lead or contribute to cross-functional initiatives that improve adjudication workflows, system capabilities, reporting, controls, and stakeholder experience. Participate in meetings, client discussions, escalation reviews, and other business-critical activities outside standard business hours when necessary to support implementation, regulatory, or client-service needs. Maintain adherence to the Capital Rx Code of Conduct, privacy

requirements, regulatory obligations, and internal policies, including identifying and reporting potential noncompliance. Minimum

Qualifications: Bachelor’s degree strongly preferred; equivalent combination of relevant education and experience may be considered. 2+ years of progressive experience in health plan, TPA, medical claims,

benefits administration, claims operations, or related healthcare operations environment. Demonstrated experience interpreting benefit plans, coverage provisions, claims policies, applicable laws and regulations, and operational

requirements to resolve complex or escalated claim matters. Proven ability to exercise discretion and independent judgment when evaluating competing information, determining appropriate claim outcomes, assessing business risk, and making recommendations on matters of significance. Strong understanding of medical claims adjudication, coordination of

benefits, adjustments, appeals, subrogation, stop-loss, member/provider inquiries, and related operational impacts. Experience leading cross-functional initiatives, influencing stakeholders, improving processes, driving high performance, meeting deadlines, and executing on deliverables. Exceptional project management, prioritization, problem-solving, communication, and organizational skills, with the ability to shift between competing priorities and meet organizational goals. Ability to communicate complex claims, benefit, operational, and client-impact issues clearly to internal and external stakeholders. Proficient in Microsoft Office Suite and able to adapt to software such as Jira, Miro, Confluence, GitHub, AWS Redshift, and other operational or reporting platforms. Ability to work effectively with virtual teams while maintaining confidentiality, privacy, and professional standards. Preferred

Qualifications: Medicare/Medicaid experience preferred New York, NY Salary Range $98,800 — $123,500 USD Denver, CO Salary Range $90,800 — $113,500 USD Charlotte, NC Salary Range $82,400 — $103,000 USD All employees are responsible for adherence to the Judi Health 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. 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. 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 .

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