Sr. Consultant, Issue Management

Due to growth, we are adding a Sr. Issue Management Consultant to our CAO Quality department.

The Sr. Issue Management Consultant plays a critical role in identifying, analyzing, and resolving claim adjudication issues to ensure accuracy, compliance, and operational efficiency. This position focuses heavily on claims reprocessing, risk mitigation, and requirement documentation, serving as a key liaison between internal business units and external clients.

Is this you? Find out more below!

How do I make an impact on my team?

Investigate reported issues to identify underlying root causes
• Apply RCA methodologies such as the 5 Whys to uncover systemic problems
• Document findings and produce comprehensive RCA reports
• Collaborate with internal partners who conduct RCA to ensure accurate issue identification
• Own the Root Cause Resolution process to remediate reported issues
• Develop and implement action plans to prevent recurrence of issues
• Integrate preventative strategies into broader quality improvement initiatives
• Provide oversight of remediation efforts to ensure completeness and accuracy
• Write clear, consistent, and compliant business requirements to support issue resolution
• Focus on reprocessing Medicare, Medicaid, Commercial, and Exchange claims
• Centralize claims reprocessing efforts to reduce operational and compliance risk
• Investigate reported issues and determine appropriate remediation steps, including policy, procedural, or configuration changes
• Communicate findings and action plans clearly to client-facing teams
• Identify opportunities for process improvement based on RCA findings
• Apply knowledge of claims processing workflows, systems, and procedures, including adjudication, resolution, and documentation standards, to ensure accuracy and compliance
• Other duties as assigned

What our team expects from you?

• Bachelor's degree or equivalent work experience required
• 4+ years of experience in root cause analysis, issue management, and preventative action planning within the PBM or healthcare industry
• Experience with RCA tools and methodologies
• Demonstrated knowledge of claims processing workflows, systems, and procedures, including adjudication, resolution, and documentation standards is required
• Proficiency in Microsoft Office Suite
• Knowledge of regulatory requirements and industry standards in PBM
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program - up to $750!

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