Senior Manager Government Program Operations (Exchange)

Location: Remote (For Non-Local) or Hybrid (Local to Denver or NYC area)

Position Summary:

The Senior Manager is responsible for leading the end‑to‑end implementation, governance, and change management of regulatory requirements for Exchange plans and EDGE Server operations. This role oversees the delivery of CMS submissions, compliance activities, contract applications, and bid‑related client support, while also coordinating responses to federal and state regulatory audits. The Senior Manager ensures all regulatory reporting obligations are met for Exchange clients by interpreting CMS and state guidance, partnering with internal subject matter experts and client teams, and translating requirements into operational processes. Using structured research, analysis, testing, and validation, this role ensures that systems, workflows, and data submissions consistently meet regulator expectations and client objectives.

 

Position Responsibilities:

• Lead Government Programs support for Exchange business functions including claims adjudication, regulatory reporting, and audit support (Government, and Client).
• Leads the interpretation, implementation and monitoring of all relevant regulatory requirements and changes impacting Capital Rx’s Exchange Programs.
• Establish and maintain the EDGE pharmacy submission playbook (file intent, lineage, duplicate controls, timestamp standards, enrollment alignment).
• Define and enforce submission cadences, pre‑submission QA gates, and accept/active/non‑orphan targets that meet CMS sufficiency timelines.
• Translate CMS updates into operational SOPs and training.
• Partners with cross‑functional SMEs to analyze regulatory changes, determine their implications for organizational processes, systems, and client commitments, and leads the coordinated, on‑time implementation of required updates across the enterprise.
• Manages timely response to Government Programs support for RFP/RFI, internal sales, and Exchange client requests.
• Provides key insights on Exchange functions using data analysis, industry knowledge and subject matter expertise to identify opportunities, and develop solutions, for optimization of internal business processes and systems.
• Supports the documentation management of internal policies and procedures, reporting and project specifications, job aids, and workflows for designated Government Programs Operations.
• Leverages profound knowledge of Exchange guidance and understanding of industry and market requirements to support product strategy and service delivery.
• Maintains current knowledge of Exchange requirements to facilitate compliance of ongoing business operations.
• Fosters a high-performance culture through mentoring and collaboration, providing team members with ongoing performance feedback and identifying required changes to existing roles and responsibilities to ensure effectiveness and efficiency.
• Assesses impact of new business to understand scalability and staffing needs.

 

Required Qualifications:

• 6+ years of relevant Prescription Benefit Management and/or Health Plan experience supporting Exchange plans
• 5+ years people management experience
• Vast knowledge of Exchange regulatory requirements and associated product and/or operational workflows
• Proven success managing multiple complex projects simultaneously
• Extremely flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product
• Excellent written and verbal communication skills
• Proven success managing cross functional teams and maintaining effective relationships at all levels both internal and external; including government entities

 

 

 

This range represents the low and high end of the anticipated base salary range for the NY - based position. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and if the location of the job changes.

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

 

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital 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.

 

Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.