Manager, Medicare Enrollment and Reconciliation

Clever Care Health Plan•Huntington Beach, CA

6d•$90,000 - $110,000

About The Position

The Manager, Enrollment & Reconciliation works to maximize the efficiency, productivity, and performance of the Enrollment Department's processes to support operations and business decisions related to the capture, exchange, and reporting of various data elements for Medicare Advantage Plan operations. This role provides guidance to direct reports, provides clarity on department priorities and goals for the Enrollment and Reconciliation function area. Serves as the organization’s expert authority on Medicare Advantage Enrollment and Reconciliation rules and regulations, including CMS eligibility policy, MARx transactions, retroactive adjustments, payment reconciliation, and audit resolution requirements. They will collaborate with other plan leaders to assess problematic findings and implement corrective action plans to improve operations.

Requirements

Bachelor’s degree or equivalent combination of education and experience.
Minimum two (2) years of enrollment and reconciliation supervisory experience.
Minimum four (4) years of Medicare Enrollment experience at the health plan level.
Demonstrated expert knowledge of Medicare Advantage Enrollment and Reconciliation rules and regulations, including CMS enrollment policy, MARx processing, payment reconciliation, and audit requirements.
Must possess expert-level knowledge of Medicare Advantage audit, compliance, enrollment, reconciliation, and regulatory reporting requirements.
Expert knowledge of Medicare Advantage enrollment transactions, reconciliation processes, and CMS enrollment policy.
Advanced understanding of MARx transaction codes, CMS response files, and enrollment reconciliation workflows.
Ability to interpret and apply CMS guidance, HPMS memos, and the Plan Communications User Guide (PCUG) to operational scenarios.
Accountable for ensuring enrollment and reconciliation processes comply with CMS regulations and do not result in adverse member impact, compliance findings, or payment discrepancies.
Highly efficient in preparing documents, managing data, and managing multiple projects simultaneously
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
Strong work ethic to meet changes in responsibilities that will take place daily.
Microsoft Excel, PowerPoint, & Word proficiency
Capacity to work independently and as a team player
Must have excellent verbal and written communication skills.
Strong leadership and mentoring qualities.
Must be able to travel when needed or required
Ability to operate a keyboard, mouse, phone, and perform repetitive motion (keyboard); writing (note-taking)
Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Nice To Haves

Master’s degree a plus.
Experience working with Market Prominence is a plus

Responsibilities

Provides expert interpretation and application of Medicare Advantage Enrollment and Reconciliation rules and regulations, including CMS enrollment eligibility policy, effective and termination date rules, retroactive adjustments, low-income subsidy indicators, and payment reconciliation impacts.
Oversees CMS MARx enrollment processing, including transaction submission, resolution of rejections and retroactive adjustments, coordination of replacement transactions, and reconciliation of CMS response files to internal enrollment systems.
Owns enrollment and payment reconciliation governance, ensuring alignment between internal systems, CMS MARx data, and downstream vendors (PBM, claims, finance), and ensuring discrepancies are identified, documented, corrected, and reported timely.
Establishes department priorities and strategies to facilitate meeting Enrollment and Reconciliation Department goals, including the identification of budgetary resource requirements, staffing projections, and other operating resources.
Assists the Department with building team member subject-matter expertise in the array of available data; understands opportunities and limitations of various data sets; Mentors, trains, and develops staff; Partners with internal teams to understand reporting needs and visualization tools.
Collaborates with various departments to identify and resolve complex issues and errors that involve internal and external systems, government data, and regulatory guidance; leads and executes complex data-related analytical projects to drive business decisions and efficiencies; ensures timely and accurate reporting, correction of issues and errors, and implements best practices. May support audits and attestations.
Oversees audits and reconciliation activities to ensure regulatory compliance, applies audit findings to improve departmental efficiency, and maintains the integrity of the enrollment files.
Maintains up-to-date knowledge of regulatory requirements and industry best practices as they relate to data. Attends CMS training sessions and other appropriate industry meetings.
Maintains oversight of department performance and established team priorities and goals to achieve strategic goals.
Work with cross-functional departments by providing support to brokers, IPA/PCPs as necessary; with an emphasis on front-line eligibility, application processing, reporting, and other data exchange problem-solving.
Other duties as assigned.