Responsible for maintaining and configuring prior authorization criteria, decision trees, and communication templates within the PA system. Partners with clinical and IT teams to ensure data integrity and translate clinical requirements into system logic.
Judi Health
35 Remote Job Openings at Judi Health
Responsible for designing, configuring, and quality-assuring prior authorization criteria and decision trees within the PA system. This includes managing member/provider communications, validating clinical intent, and collaborating with external clients for delegated services.
Lead and scale the quality assurance strategy across engineering teams with a focus on test automation and process optimization. Manage a team of QA engineers while collaborating with product and engineering leadership to align testing priorities with business goals.
The role focuses on the intake, triage, and validation of client services issues to ensure accurate routing and visibility. It involves creating process documentation and identifying workflow gaps to reduce manual work and improve operational efficiency.
The Analyst supports the full lifecycle of regulatory and client audits by coordinating deliverables and maintaining documentation repositories. They are responsible for tracking corrective actions and ensuring timely, consistent responses to audit requests.
The Analyst manages the governance and tracking of client performance guarantees and contract commitments. This includes maintaining accurate data, supporting reporting needs, and collaborating with Legal and Finance teams to identify risks.
Act as the primary point of contact for members and prescribers regarding pharmacy benefit inquiries and prior authorization requests. Triage incoming calls, resolve customer concerns, and collaborate with internal clinical teams to ensure quality care.
Utilization Management Appeals Technician (temp-to-hire)
Judi Health
·
Part Time
·
17 days ago
Judi Health
Responsible for processing first, second level, and external appeals for various lines of business while ensuring high customer service and productivity. The role involves verifying case qualifications, coordinating with pharmacists and medical directors, and maintaining strict adherence to HIPAA guidelines.
Support the PBA account teams by managing day-to-day client requirements, benefit requests, and new implementations. Lead quality assurance testing and claim reviews to ensure coding accuracy and resolve sponsor or member issues.
The analyst monitors federal and state regulatory sources to assess the business impact of changes on government programs. They coordinate cross-functional implementation plans and maintain documentation to ensure audit readiness and compliance.
The role involves managing eligibility data exchange, coordinating with external partners on file formats, and resolving data transfer errors. The analyst will act as a subject matter expert on EDI protocols to ensure data integrity and accuracy.
Lead the national go-to-market strategy to acquire new TPA and health plan clients for the Judi SaaS platform. Manage the full enterprise sales cycle from prospecting and discovery to commercial negotiation and closing.
Responsible for reviewing clinical coverage determinations and appeals for Commercial and Medicare lines of business based on medical necessity. This includes collaborating with Medical Directors, performing peer-to-peer reviews, and documenting decisions using scientific literature.
Prepare and validate prior authorization requests by obtaining necessary clinical information from providers and prescribers. Triage communications from members and pharmacies while ensuring adherence to HIPAA guidelines and internal operating procedures.
Develop and productionize multimodal LLMs and AI-based automation tools for healthcare applications. Manage the full ML lifecycle from data pipeline creation and fine-tuning to deployment and security compliance.
Lead and mentor a team of IT Engineers to oversee day-to-day operations and the delivery of enterprise IT services. Drive strategic initiatives to improve identity, endpoint management, and SaaS platforms while serving as the final escalation point for technical issues.
The Medical Director performs medication utilization reviews and medical necessity appeals for various client programs. They provide peer-to-peer support to prescribers and contribute to the development of clinical policies and UM criteria.
The developer will build and enhance a web-based enterprise health platform by implementing new features and improving existing functionality. This includes writing clean, maintainable code and collaborating with product managers and designers in an Agile environment.
Collaborate with product managers and engineers to execute the product roadmap and deliver member experience enhancements. Responsibilities include triaging technical data errors, building business requirements, and managing the product backlog.
Responsible for the day-to-day operations of group benefits programs, including vendor management and employee support. Ensures regulatory compliance for benefits and leave programs while managing open enrollment and HRIS data accuracy.
Utilization Management Pharmacist (Temp, Temp-to-hire)
Judi Health
·
Part Time
·
2 months ago
Judi Health
The pharmacist reviews prior authorization requests, appeals, and overrides using evidence-based clinical guidelines. They provide expert guidance to members, providers, and pharmacies while ensuring compliance with regulatory standards.
Manage large commercial pharmacy benefit accounts by serving as the primary relationship liaison and developing strategic plans. Oversee client renewals, performance guarantee reporting, and provide proactive recommendations based on healthcare trends.
Manage the full client lifecycle from implementation to renewal, focusing on benefit changes and pricing accuracy for PBA and Medicare plans. Lead quality assurance initiatives and claim reviews to ensure operational efficiency and high client satisfaction.
The Appeals Technician is responsible for managing incoming first, second, and external appeals while ensuring high-quality customer service and productivity. They must maintain compliance with HIPAA guidelines, perform quality reviews, and coordinate with pharmacists and medical directors to process cases efficiently.
The UX/UI Designer will create user-centered interfaces and experiences while ensuring visual consistency and accessibility across product features. They will collaborate with cross-functional teams to conduct usability testing and maintain the design system.
The Senior Project Manager will lead the development and execution of pharmacy benefit cost-savings programs across various lines of business. This role involves managing cross-functional teams, overseeing vendor relationships, and utilizing data analytics to drive program quality and continuous improvement.
The Senior Project Manager will lead the development and execution of market access programs across various lines of business while managing vendor relationships and operational workflows. They will also collaborate with analytics teams to assess program performance and support commercialization efforts through pricing and marketing enablement.
The Clinical Account Manager will lead and develop relationships with key healthcare decision-makers to ensure client satisfaction and retention. They will analyze pharmacy claims data to provide actionable clinical insights and strategic recommendations.
The VP of Provider Reimbursement and Contracting will architect and advance network solutions, integrating payment innovation and high-performing provider partnerships. This role involves leading provider contract negotiations, developing value-based payment models, and aligning network strategies with product design to optimize total cost of care.
The Case Underwriter will execute day-to-day pricing and underwriting for new and renewing business opportunities while collaborating with sales and executive teams. They are responsible for refining financial models, supporting client contracting, and maintaining underwriting system infrastructure.
The Clinical Account Consultant will manage client clinical needs, including formulary strategy, trend analysis, and clinical plan implementation. They will also collaborate with cross-functional teams to support sales initiatives and contribute to clinical process improvements.
This role involves combining technical leadership with hands-on coding to develop scalable, high-impact healthcare technology, exercising leadership over features from design through delivery. Responsibilities include partnering with product, design, and QA teams, becoming a subject matter expert, and expanding the enterprise health platform using specified technologies.
Senior Manager Government Program Operations (Exchange)
Judi Health
·
Full Time
·
5 months ago
Judi Health
The Senior Manager leads the end-to-end implementation, governance, and change management of regulatory requirements for Exchange plans and EDGE Server operations, overseeing CMS submissions, compliance, and audit responses. This role involves interpreting CMS and state guidance to ensure all regulatory reporting obligations for Exchange clients are met through structured research, analysis, testing, and validation of systems and workflows.
The Clinical Program Business Development Manager will drive the sales strategy for Capital Rx’s clinical programs, from prospecting to closing deals. This role involves assessing client data, delivering presentations, and managing relationships to foster program adoption.
The Senior AI/ML Applied Scientist will investigate and evaluate the latest LLM and MLM models for healthcare applications, develop data pipelines, and productionize machine learning solutions. They will also participate in the complete lifecycle of ML model development and ensure compliance with healthcare data regulations.
