Product Manager, Claim Adjudication (GP)
Navitus Health Solutions, Madison, WI, United States
Product Manager, Claim Adjudication (GP)
Location : US
ID : 2026-5739
Category : Development
Position Type : Full-Time
Remote : Yes
About 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. Our team celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.
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.
Pay USD $82,586.00 - USD $101,333.00 /Yr.
STAR Bonus
(At Risk Maximum): 5.00
Work Schedule M-F 8am to 5pm CT
Remote Work Notice 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.
Overview 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!
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, including 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 results to improve claim adjudication accuracy
Ensure metrics are monitored and reported
Create and maintain claim adjudication training resources
Other duties as assigned
Qualifications
College degree or equivalent experience required in managed care or health insurance
Minimum of two years' experience with Medicare claims adjudication preferred
Has successfully led 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 Navitus Offers
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 up to 5% with no vesting requirement
Adoption Assistance Program
Flexible Spending Account
Educational Assistance Plan and Professional Membership assistance
Referral Bonus Program – up to $750
Location Remote
Location: Country US
About the role status This description reflects the current job opportunity and is not a guarantee of employment. No separate postings exist for this role at this time.
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ID : 2026-5739
Category : Development
Position Type : Full-Time
Remote : Yes
About 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. Our team celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.
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.
Pay USD $82,586.00 - USD $101,333.00 /Yr.
STAR Bonus
(At Risk Maximum): 5.00
Work Schedule M-F 8am to 5pm CT
Remote Work Notice 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.
Overview 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!
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, including 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 results to improve claim adjudication accuracy
Ensure metrics are monitored and reported
Create and maintain claim adjudication training resources
Other duties as assigned
Qualifications
College degree or equivalent experience required in managed care or health insurance
Minimum of two years' experience with Medicare claims adjudication preferred
Has successfully led 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 Navitus Offers
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 up to 5% with no vesting requirement
Adoption Assistance Program
Flexible Spending Account
Educational Assistance Plan and Professional Membership assistance
Referral Bonus Program – up to $750
Location Remote
Location: Country US
About the role status This description reflects the current job opportunity and is not a guarantee of employment. No separate postings exist for this role at this time.
#J-18808-Ljbffr