Location: Hybrid (Local to Denver, CO, NYC area or Charlotte, NC)
Position Summary:The Senior Manager, Government Programs Operations is responsible for the overall implementation, operational oversight, and change management of regulatory requirements for Exchange lines of business. This role leads the delivery of regulatory reporting, claims operations support, audit readiness, and client deliverables, ensuring compliance with federal and state requirements. The person will collaborate with Legal/Regulatory teams, internal subject matter experts, and client stakeholders to interpret CMS and state guidance and translate requirements into operational processes, system capabilities, and scalable solutions. Through research, analysis, testing, and validation, this role ensures that Exchange program operations achieve contractual, regulatory compliance, and business performance objectives.
Position Responsibilities:- Lead Government Programs support for Exchange operations, including claims adjudication, regulatory reporting, and audit support (Government and Client)
- Oversee day-to-day operational performance for Exchange programs, ensuring alignment with contractual, regulatory requirements, and client expectations
- Lead the interpretation, implementation, and monitoring of federal and state regulatory requirements impacting Exchange lines of business
- Collaborate cross-functionally with SMEs (Claims, Product, Technology, Compliance, Legal) to assess regulatory impacts and ensure timely, coordinated implementation of required changes
- Design, document, and scale operational processes that enable accurate, compliant, and efficient service delivery
- Define business and system requirements to support compliant claims processing, data accuracy, and reporting outcomes
- Lead regulatory reporting activities and ensure completeness, accuracy, and timeliness of all required submissions
- Support internal and external audits by federal and state agencies, including audit preparation, documentation, issue response, and remediation tracking
- Monitor Exchange program operations to identify and resolve issues, including root cause analysis and implementation of corrective actions
- Partner with stakeholders to manage error handling, operational exceptions, and process improvements across claims and reporting functions
- Identify opportunities to enhance operational performance, compliance, and scalability through process improvement and innovation
- Own and maintain documentation of policies and procedures, reporting specifications, job aids, and workflows for Government Programs Operations
- Maintain current knowledge of Exchange regulatory requirements and market trends to support compliance and strategic decision-making
- Provide data-driven insights to improve operational effectiveness, reporting accuracy, and overall program performance
- Foster a high-performance culture through mentoring, collaboration, and ongoing performance feedback
- Assess impact of new business and regulatory changes to ensure appropriate scalability, resource planning, and organizational readiness
Required Qualifications:- 6+ years of relevant Prescription Benefit Management and/or Health Plan experience supporting Exchange programs
- 5+ years people management experience
- Subject matter expertise of Exchange regulatory requirements and associated product and/or operational workflows
- Demonstrated experience supporting regulatory reporting, audits, and compliance activities
- 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
- Strong operational mindset with experience improving processes and driving execution
- Ability to translate regulatory guidance into business and system requirements
- Extremely flexible, highly organized, and able to shift priorities in a fast-paced environment
- Strong analytical skills and experience leveraging data to support decision-making
- Attention to detail and commitment to delivering high-quality work product
- Excellent written and verbal communication skills
- Proven ability to manage cross-functional teams and build effective relationships across internal and external stakeholders, 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.New York, NY Salary Range
$155,000-$165,200 USD
Denver, CO Salary Range
$14,500-$155,000 USD
Charlotte, NC Salary Range
$137,600-$145,000 USD
All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
