Reconciliation & Quality Advisor, Individual Dental Operations

Job not on LinkedIn

🔥 2 hours ago

🐊 Florida, Missouri, +2 more states – Remote

🐊 Florida – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🤠 Texas – 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

Founded 1982

🏥 Healthcare

⚕️ Healthcare Insurance

💊 Pharmaceuticals

Healthcare • Healthcare Insurance • Pharmaceuticals

The Cigna Group is a global health company committed to improving the health and vitality of its clients, customers, and patients. With its two divisions, Cigna Healthcare and Evernorth Health Services, the company focuses on enhancing quality of life through healthcare services and pharmacy benefits management. The Cigna Group is dedicated to ethical practices in healthcare and artificial intelligence, and strives to create positive change in the healthcare system. It also emphasizes its Environmental, Social, and Governance (ESG) responsibilities, aiming to impact health equity and foster innovation in healthcare delivery.

📋 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 subject matter expert and accountable business contact for ACA Marketplace enrollment and policy-based payment reconciliation across Individual Dental Operations • Act as primary enrollment-alignment contact for the Centers for Medicare & Medicaid Services • Research complex enrollment and financial discrepancies, determine root causes, assess business impact, and drive corrective action • Develop trend analyses and actionable insights to improve reconciliation accuracy and operational efficiency • Maintain knowledge of federal and state regulations, sub-regulatory guidance, and Marketplace requirements • Perform independent quality reviews of reconciliation processes, discrepancy resolutions, control evidence, and reporting • Establish quality review standards, sampling approaches, review criteria, issue-severity definitions, and acceptance thresholds • Identify control gaps and recommend remediation, process improvement, and risk-reduction priorities • Validate corrective actions through follow-up reviews, evidence testing, and documented closure recommendations • Coordinate regulatory, financial, operational, and audit requests • Oversee third-party administrator and vendor performance • Partner with vendors, internal matrix partners, and Marketplace representatives to resolve discrepancies • Influence operational and technology partners to implement sustainable process and system improvements • Coach partners on reconciliation standards, control expectations, documentation quality, and issue resolution • Govern reconciliation documentation, including policies, procedures, business rules, control evidence, technical requirements, and decision logs • Produce weekly, monthly, and ad hoc reporting, including scorecards, aging and inventory views, risk summaries, remediation status, and quality assessments • Develop executive-ready quality assessments and communicate status, risks, decisions, dependencies, and remediation plans • Lead or support ACA Medical reconciliation activities during Medical wind-down and 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 • Internet connection obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload when working at home occasionally or permanently

🏖️ Benefits

• Remote work arrangement • Tobacco-free policy • Reasonable accommodation for the online application process