Manager, Medicare Enrollment and Reconciliation

Overview

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.

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.

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.

• 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.