Product Manager, Claim Adjudication, Medicaid/Medicare

Navitus Health Solutions is dedicated to making medications more affordable and improving pharmacy benefit management. The Claims Adjudication Product Manager will ensure that claims are processed according to regulations and client needs while collaborating with various teams to enhance the adjudication process.

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
• 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
• On-call availability
• Some travel may be required