Position SummaryThe Individual Dental Reconciliation and Quality Advisor has primary responsibility for Affordable Care Act Marketplace reconciliation supporting Individual Dental products. This role independently leads reconciliation strategy, execution, issue resolution, compliance readiness, vendor oversight, reporting, and cross-functional coordination.
The Advisor also serves as an independent quality reviewer and trusted business advisor, assessing process execution, control effectiveness, data integrity, and remediation quality. The role translates findings into practical recommendations for operational leaders, technology partners, and vendors and helps ensure reconciliation activities remain accurate, timely, compliant, sustainable, and aligned with financial, customer, regulatory, and audit requirements.
Key ResponsibilitiesReconciliation Leadership and Execution- Own end-to-end ACA Marketplace reconciliation for Individual Dental plans, including operational controls, file and transaction monitoring, discrepancy management, financial alignment, reporting, and issue escalation.
- Serve as the primary subject matter expert and accountable business contact for ACA Marketplace enrollment and policy-based payment reconciliation across Individual Dental Operations.
- Act as the primary enrollment-alignment contact for the Centers for Medicare & Medicaid Services.
- Independently research complex enrollment and financial discrepancies, determining root cause, business impact, resolution approach, and required corrective action.
- Develop trend analyses and actionable insights to improve reconciliation accuracy, reduce aging and resolution times, strengthen first-contact resolution, and prevent recurring issues.
- Use data-driven analysis to prioritize work, strengthen operational controls, improve data quality, reduce manual effort, and increase efficiency.
Compliance, Controls, and Quality Advisory- Maintain current knowledge of federal and state regulations, sub-regulatory guidance, and Marketplace requirements applicable to ACA Dental reconciliation.
- Perform independent quality reviews of reconciliation processes, discrepancy resolutions, control evidence, and reporting to confirm accuracy, completeness, consistency, and adherence to established requirements.
- Establish and maintain quality review standards, sampling approaches, review criteria, issue-severity definitions, and documented acceptance thresholds.
- Identify systemic trends and emerging control gaps and recommend priorities for remediation, process improvement, and risk reduction.
- Validate that corrective actions address identified root causes and produce sustainable results through follow-up reviews, evidence testing, and documented closure recommendations.
- Provide objective challenge and consultation on proposed operational, control, technology, and vendor changes to confirm that solutions are sustainable, auditable, and aligned with business and compliance expectations.
- Coordinate regulatory, financial, operational, and audit requests within the assigned reconciliation scope, ensuring complete evidence, timely responses, and documented issue closure.
Vendor and Cross-Functional Partnership- Oversee third-party administrator and vendor performance by maintaining accurate reconciliation inventories, validating execution status, reviewing discrepancy resolutions, and escalating material gaps.
- Partner with enrollment and billing vendors, internal matrix partners, and federal and state Marketplace representatives to resolve discrepancies and sustain compliant reconciliation outcomes.
- Influence operational and technology partners to design and implement sustainable process and system improvements that strengthen oversight, data consistency, auditability, cost effectiveness, and long-term Dental operations.
- Serve as a trusted advisor to operational leaders, matrix partners, and vendors by interpreting quality findings, evaluating risks, and recommending corrective and preventive actions.
- Promote consistent quality practices by coaching partners on reconciliation standards, control expectations, documentation quality, and effective issue resolution.
Reporting, Documentation, and Risk Management- Define, maintain, and govern critical reconciliation documentation, including policies, standard operating procedures, business rules, control evidence, technical requirements, and decision logs.
- Produce accurate and timely weekly, monthly, and ad hoc reporting, including reconciliation scorecards, aging and inventory views, risk summaries, remediation status, and quality assessments.
- Develop executive-ready quality assessments that clearly distinguish observations, risks, root causes, required actions, accountable owners, and closure status.
- Communicate reconciliation status, emerging risks, decisions, dependencies, and remediation plans to leadership and cross-functional partners, providing clear recommendations and required actions.
- Identify risks early, make informed decisions within delegated authority, and escalate matters that could affect regulatory compliance, financial accuracy, customers, or vendor delivery.
- Lead or support ACA Medical reconciliation activities during the Medical wind-down and applicable regulatory runout periods.
Required Qualifications- Bachelor's degree.
- At least five years of experience in healthcare insurance operations, enrollment, billing, financial reconciliation, or a related discipline preferred.
- Experience with Affordable Care Act Individual Marketplace business and reconciliation processes strongly preferred.
- Demonstrated ability to independently own complex operational responsibilities, establish priorities, make informed decisions, and drive results across matrixed teams.
- Strong knowledge of operational controls, regulatory compliance, audit readiness, issue management, and root-cause analysis.
- Experience performing quality assurance, control testing, operational assessments, or independent reviews and translating findings into actionable recommendations.
- Proficiency with Microsoft Excel, Word, PowerPoint, and Outlook. Experience with reporting, data visualization, or workflow automation tools is preferred.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
