About the role
About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Judi 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
Responsibilities: Provide oversight for vendors conducting utilization management, care management, and clinical operations activities. Oversee vendor execution of utilization reviews, including prospective, concurrent, and retrospective reviews, to ensure medical necessity and appropriate level of care determinations. Monitor vendor review of medical records and treatment plans to support appropriate service utilization, avoid unnecessary or duplicate services, and optimize reimbursement outcomes. Partner with the Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations. Provide oversight of vendor-managed prior authorization, peer-to-peer review, denial, appeal, and notification processes. Ensure vendors complete comprehensive biopsychosocial assessments and health risk assessments (HRAs) in accordance with program
requirements. Oversee vendor-led care coordination across the continuum, including transitions of care and discharge planning. Provide oversight of vendor-administered chronic disease and complex case management programs. Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care. Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented. Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA
