Reconciliation & Quality Advisor, Individual Dental Operations

Job not on LinkedIn

🔥 6 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

⚙️ Operations

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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The Cigna Group

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

The Cigna Group is a global health services company that provides medical, dental, pharmacy, behavioral and supplemental insurance products and benefits to individuals, families, employers, brokers, providers and Medicare beneficiaries. It offers employer-sponsored group plans, individual and family plans (including Open Enrollment offerings), Medicare, international health insurance covering more than 200 countries, and digital member services through the myCigna platform (including telehealth and claims management). Its products are delivered through operating subsidiaries such as Cigna Health and Life Insurance Company and other regional affiliates.

📋 Description

• 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 • Research complex enrollment and financial discrepancies and determine root cause, business impact, resolution approach, and 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 • Maintain 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 • Establish and maintain quality review standards, sampling approaches, review criteria, issue-severity definitions, and documented acceptance thresholds • Identify systemic trends and control gaps and recommend remediation, process improvement, and risk-reduction priorities • Validate corrective actions through follow-up reviews, evidence testing, and documented closure recommendations • Provide objective challenge and consultation on operational, control, technology, and vendor changes • Coordinate regulatory, financial, operational, and audit requests within the assigned reconciliation scope • Oversee third-party administrator and vendor performance, including reconciliation inventories, execution status, discrepancy resolutions, and escalation of material gaps • Partner with enrollment and billing vendors, internal matrix partners, and federal and state Marketplace representatives to resolve discrepancies • Influence operational and technology partners to implement sustainable process and system improvements • Serve as a trusted advisor to operational leaders, matrix partners, and vendors • Coach partners on reconciliation standards, control expectations, documentation quality, and issue resolution • Define, maintain, and govern reconciliation documentation, including policies, standard operating procedures, business rules, control evidence, technical requirements, and decision logs • Produce 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 distinguishing 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 • Identify risks early, make decisions within delegated authority, and escalate matters affecting regulatory compliance, financial accuracy, customers, or vendor delivery • Lead or support ACA Medical reconciliation activities during Medical wind-down and applicable regulatory runout periods

🎯 Requirements

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

🏖️ Benefits

• Remote work option • Internet service requirement support/eligibility for working from home: cable broadband or fiber optic service with at least 10Mbps download/5Mbps upload • Tobacco-free policy • Reasonable accommodation support for the online application process