Sr. Consultant, Issue Management

Sr. Issue Management Consultant

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!

Responsibilities

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

Qualifications

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!

Location : Remote

Location : US