Claims Adjudication Associate

Location: Hybrid (Local to NYC, Denver, or Charlotte area)

Position Summary:

Capital Rx is seeking a self-driven Claims Adjudication associate to support the Medical claims adjudication workflow for JUDI Health, Capital Rx’s enterprise health platform.

The Claims Adjudication Associate is responsible for evaluating claims submitted by policyholders or providers to determine their validity, coverage, and proper reimbursement amounts. They serve as the critical link between the services rendered and financial compensation, aiming to prevent improper payments and resolve billing disputes.

Position Responsibilities:

• Evaluate complex medical claims, coverage issues, and benefit determinations by reviewing claim facts, plan documents, applicable laws and regulations, medical coding information, and supporting documentation to determine or recommend appropriate claim outcomes.
• Interprets complex policy and benefit language, identifying applicable coverage provisions, assessing claim risk, and resolving escalated or non-routine claim matters.
• Make coverage, liability, payment, adjustment, recovery, subrogation, stop-loss, and recoupment determinations or recommendations that have financial, operational, client, or regulatory impact.
• Negotiate or support resolution of complex claim issues with internal stakeholders, providers, members, networks, and other parties, including escalation of significant matters and recommendations for settlement or corrective action when appropriate.
• Serve as a subject matter resource to Customer Care, Operations, and other client-facing teams by providing guidance on complex claims, benefit interpretation, adjudication logic, inquiry management, and claim-resolution strategy.
• Manage and prioritize escalated claims-related workflows, including appeals, subrogation, payment issues, stop-loss, adjustments, and member/provider inquiries, based on contractual obligations, regulatory 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