Reconciliation & Quality Advisor, Individual Dental Operations

This is a fully remote position, open to applicants in Florida, +3 more states.

📋 Description

• Manage comprehensive ACA Marketplace reconciliation for Individual Dental plans, encompassing operational controls, file and transaction oversight, discrepancy resolution, financial alignment, reporting, and issue escalation.

• Act as the subject matter expert and primary business contact for ACA Marketplace enrollment and policy-based payment reconciliation within Individual Dental Operations.

• Serve as the main enrollment-alignment liaison for the Centers for Medicare & Medicaid Services.

• Investigate complex enrollment and financial discrepancies, identify root causes, evaluate business impact, and initiate corrective actions.

• Create trend analyses and actionable insights aimed at enhancing reconciliation accuracy and operational efficiency.

• Stay informed on federal and state regulations, sub-regulatory guidance, and Marketplace requirements.

• Conduct independent quality assessments of reconciliation processes, discrepancy resolutions, control evidence, and reporting.

• Develop quality review standards, sampling methods, review criteria, definitions of issue severity, and acceptance benchmarks.

• Identify control weaknesses and propose remediation strategies, process enhancements, and risk-reduction initiatives.

• Confirm corrective actions through follow-up reviews, evidence testing, and documented closure recommendations.

• Manage regulatory, financial, operational, and audit requests.

• Supervise the performance of third-party administrators and vendors.

• Collaborate with vendors, internal matrix partners, and Marketplace representatives to address discrepancies.

• Influence operational and technology partners to adopt sustainable process and system improvements.

• Guide partners on reconciliation standards, control expectations, documentation quality, and issue resolution.

• Oversee reconciliation documentation, which includes policies, procedures, business rules, control evidence, technical requirements, and decision logs.

• Generate weekly, monthly, and ad hoc reports, including scorecards, aging and inventory views, risk summaries, remediation statuses, and quality assessments.

• Develop executive-ready quality assessments and communicate status, risks, decisions, dependencies, and remediation plans.

• Lead or assist in ACA Medical reconciliation efforts during Medical wind-down and regulatory runout phases.

⛳️ Requirements

• Bachelor’s degree.

• Minimum of five years’ experience in healthcare insurance operations, enrollment, billing, financial reconciliation, or a related field preferred.

• Strong preference for experience with Affordable Care Act Individual Marketplace business and reconciliation processes.

• Capacity to independently manage complex operational responsibilities, prioritize tasks, make informed decisions, and drive results across matrixed teams.

• Robust knowledge of operational controls, regulatory compliance, audit preparedness, issue management, and root-cause analysis.

• Experience in quality assurance, control testing, operational assessments, or independent reviews, with the ability to translate findings into actionable recommendations.

• Proficiency in Microsoft Excel, Word, PowerPoint, and Outlook.

• Internet connection through a cable broadband or fiber optic service provider with minimum speeds of 10Mbps download and 5Mbps upload when working remotely.

🏝️ Benefits

• Remote work arrangement.

• Tobacco-free policy.

• Reasonable accommodations for the online application process.