Government Program Operations Manager – Analysis & Efficiencies

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

Position Summary:

The Government Programs Operations Manager is responsible for overseeing the implementation, compliance, and optimization of Medicare, Medicaid, and Exchange programs. This position blends regulatory expertise with operational innovation to ensure that government program operations are both compliant and technically efficient.

This manager will lead a team dedicated to identifying, developing, and maintaining technical analysis and efficiencies across the department. Responsibilities include designing automated solutions, validating the accuracy of outgoing deliverables, and establishing scalable processes that support regulatory and business objectives. The role also involves interpreting CMS and state guidance, collaborating with internal subject matter experts and clients, and ensuring that system capabilities align with both regulatory intent and client needs.

In addition, the manager drives data-informed decision-making by overseeing the analysis of complex datasets to identify trends, outliers, and opportunities for process improvement. This includes creating detailed specifications for reports and operational tools and working closely with cross-functional teams—such as compliance, product, sales, marketing, underwriting, implementation, client services, and clinical operations—to enhance and maintain operational capabilities

Position Responsibilities:

• Interpret and operationalize CMS/state regulatory and sub-regulatory guidance in collaboration with Compliance and internal SMEs
• Oversee timely implementation of regulatory changes, coordinating cross-functional workplans across impacted departments
• Monitor internal operations for government programs, identify and resolve errors through root cause analysis, and implement corrective actions
• Support claims correction activities related to retro-eligibility and coordination of benefits (COB), while placing focus on the accurate reprocessing of claims
• Support internal, client, and government audits by ensuring data accuracy, process transparency, and documentation completeness
• Drive team to maintain comprehensive documentation including policies, procedures, job aids, workflows, and reporting specifications
• Lead the development of automated tools and scalable solutions to improve operational efficiency and data accuracy
• Analyze complex encounter and PDE data using internal and external sources to identify trends, outliers, and improvement opportunities
• Define and document business and reporting requirements to support system enhancements and process improvements
• Track performance metrics for encounter and PDE submissions, ensuring alignment with client and regulatory expectations
• Promote subject matter expertise within the team by encouraging proactive process reviews and knowledge sharing for purpose of establishing continuity within the team and its processes
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Required Qualifications:

• 5+ years of healthcare data experience
• 5+ years of relevant PBM and/or Health Plan experience supporting Medicare Part D, Medicaid, or Exchange plans
• 5+ years of experience working with SQL, R, or Python
• Experience working with cross-functional teams

• Skills & Tags

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