Claims Adjudication Associate

Back to jobsClaims Adjudication AssociateNew York, New York, United StatesApplyAbout Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Judi 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. To learn more, visit www.judi.health.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...