Reconciliation & Quality Advisor, Individual Dental Operations

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Take ownership of the complete ACA Marketplace reconciliation for Individual Dental plans, encompassing operational controls, file and transaction monitoring, discrepancy management, financial alignment, reporting, and issue escalation.

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

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

• Investigate complex enrollment and financial discrepancies to identify root causes, assess business impact, develop resolution strategies, and implement corrective actions.

• Generate trend analyses and actionable insights aimed at enhancing reconciliation accuracy, decreasing aging and resolution times, bolstering first-contact resolution, and preventing recurring issues.

• Leverage data-driven analysis to prioritize tasks, enhance operational controls, improve data quality, minimize manual efforts, and boost efficiency.

• Stay informed on federal and state regulations, sub-regulatory guidance, and Marketplace requirements pertinent to ACA Dental reconciliation.

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

• Establish and uphold quality review standards, sampling methodologies, review criteria, issue-severity definitions, and documented acceptance thresholds.

• Detect systemic trends and control deficiencies, and propose remediation strategies, process enhancements, and risk-reduction priorities.

• Validate corrective actions through follow-up reviews, evidence testing, and documented closure suggestions.

• Offer objective challenges and consultations regarding operational, control, technology, and vendor changes.

• Coordinate regulatory, financial, operational, and audit requests within the designated reconciliation scope.

• Supervise third-party administrator and vendor performance, including reconciliation inventories, execution statuses, discrepancy resolutions, and escalation of significant gaps.

• Collaborate with enrollment and billing vendors, internal matrix partners, and federal and state Marketplace representatives to address discrepancies.

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

• Act as a trusted advisor to operational leaders, matrix partners, and vendors.

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

• Define, maintain, and manage reconciliation documentation, including policies, standard operating procedures, business rules, control evidence, technical requirements, and decision logs.

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

• Develop executive-ready quality assessments that highlight observations, risks, root causes, required actions, accountable owners, and closure statuses.

• Communicate reconciliation status, emerging risks, decisions, dependencies, and remediation plans to leadership and cross-functional partners.

• Proactively identify risks, make decisions within delegated authority, and escalate issues impacting regulatory compliance, financial accuracy, customer satisfaction, or vendor delivery.

• Lead or assist with ACA Medical reconciliation activities during the Medical wind-down and applicable regulatory runout periods.

⛳️ Requirements

• Bachelor's degree.

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

• Strongly preferred experience with Affordable Care Act Individual Marketplace business and reconciliation processes.

• Capability to independently manage complex operational responsibilities, set priorities, make informed decisions, and achieve results across matrixed teams.

• In-depth knowledge of operational controls, regulatory compliance, audit readiness, issue management, and root-cause analysis.

• Experience in quality assurance, control testing, operational assessments, or independent reviews, with a focus on translating findings into actionable recommendations.

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

• Preferred experience with reporting, data visualization, or workflow automation tools.

• For remote work, a reliable internet connection must be obtained through a cable broadband or fiber optic service provider with speeds of at least 10Mbps download/5Mbps upload.

🏝️ Benefits

• Option for remote work.

• Support/eligibility for internet service requirements for home-based work: cable broadband or fiber optic service with at least 10Mbps download/5Mbps upload.

• Tobacco-free workplace policy.

• Support for reasonable accommodations during the online application process.