Manager, Medicare Enrollment and Reconciliation

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary
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.

Functions & Job 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.

Leadership Expectations
By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

• Model the Way:
• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values
• Inspire a Shared Vision
• Envision the future by imagining and sharing exciting possibilities
• Enlist others in a common vision by appealing to shared ambitions
• Challenge the Process
• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience
• Enable Others to Act
• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence
• Encourage the Heart
• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community

Qualifications
Qualifications
Education & Experience:

• Bachelor's degree or equivalent combination of education and experience. Master's degree a plus.
• 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.

Skills:

• 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.
• Experience working with Market Prominence is a plus

Wage Rage:
$90,000/year to $110,000/year

Physical & Working Environment.
Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• 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.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and the public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate's state residency.