Product Manager, Claim Adjudication, Medicaid/Medicare

Navitus Health Solutions is committed to making medications more affordable through innovative pharmacy benefit management. They are seeking a Claims Adjudication Product Manager to ensure compliance with CMS regulations and client needs while collaborating with various teams for continuous improvement in claims adjudication.

Responsibilities:

• 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

Requirements:

• College degree or equivalent experience required in managed care or health insurance
• Has successfully lead root cause analysis projects
• 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
• Minimum of two years' experience with Medicare claims adjudication preferred
• Project Management and/or Business Analyst experience a plus
• Data analysis experience a plus