Reconciliation Lead with extensive knowledge in the Affordable Care Act (ACA) reconciliation processes. Deep understanding of the ACA reconciliation lifecycle, including Pre-Audit, RCNI, RCNO, and ER&R submissions. Overseeing activities related to reconciliation initiatives, coordinating between teams, and ensuring compliance with ACA regulations.Key Responsibilities:Project Management:Lead and coordinate ACA reconciliation projects from initiation to completion within recon operations.Develop detailed project plans, including timelines, milestones, and deliverables.Coordinate with internal teams, stakeholders, and external partners to ensure project goals are met.Monitor initiatives/projects and make adjustments as necessary to ensure successful project delivery.ACA ReconciliationProcess Knowledge:Understand and oversee the Pre-Audit process, ensuring the accuracy and completeness of enrollment data extracted from the FFM (Federally Facilitated Marketplace).Familiar with RCNI (Inbound Enrollment Reconciliation) submissions, ensuring correct data format and content.Review and interpret RCNO (Outbound Enrollment Reconciliation) files to identify and resolve discrepancies between issuer and FFM records.Manage ERR (Enrollment Reconciliation & Resolution) submissions for handling unresolved discrepancies.Compliance and Reporting:Ensure all ACA reconciliation activities comply with CMS guidelines and timelines.Generate regular status reports for senior management, detailing project progress, issues, and risk mitigation strategies.Maintain comprehensive documentation of reconciliation processes and outcomes.Stakeholder Communication:Serve as the primary point of contact for all ACA reconciliation-related inquiries.Facilitate communication between CMS, issuers, and internal teams to address and resolve any issues promptly.Conduct training sessions and provide guidance to team members on ACA reconciliation processes and best practices.

Responsible for overseeing and managing the enrollment and billing processes for the commercial, Medicaid, and ACA lines of business. Leading a team of enrollment and billing specialists and Analyst to ensure accurate and timely enrollment of members and premium billing.• Develop and implement enrollment and billing procedures and workflows for clients consistent with client specified guidelines.• Monitor enrollment and billing related operational trends and identify opportunities for process improvements.• Partner with cross functional operational teams to analyze enrollment and billing information and recommend solutions.• Implement new processes, technologies, and systems to improve and streamline enrollment processes and resource utilization.• Develop and execute strategies to achieve key performance measures.• Monitor regulatory guidelines for impact to commercial enrollment and billing processes and take appropriate action.

Provide day-to-day operational oversight of enrollment & billing tasks for clients by; Generating and analyzing daily reports, Facilitating client meetings, Managing client expectations & escalations Identify opportunities for process improvement while ensuring accuracy and compliance requirements are intact Maintain up to date Enrollment Business Requirement Documents, Desk-Level Procedures, and Job Aids that meet compliance & client requirements Assist Enrollment & Billing processing teams with troubleshooting technical issues Work with appropriate Product, Hosting, or Security teams to assist in issue resolution. Submit required tickets including supporting documents that accurately describe the system issue Monitor regulatory agency notices for impact to Enrollment & Billing processes Review software release documents and implement new functionality as needed Work with testing team ensure test cases are accurate Update Desk Level Procedure (DLP’s) to incorporate new technology/functionality Review system/process changes with the processing team to ensure in-depth understanding. -Gathering requirements and translating those requirements to useful information for the technical teams-Understanding technicalrequirements and how they affect all IT systems in the bigger picture-Data mapping and documentation-Liaison between the business and development/ data warehouse team to support their system implementation to QNXT- Use significant experience of how member information is stored inQNXT. Member demographics and enrollment, PCP, capitation, COB and understanding attribute configuration.- Create a data mapping (member centric data) from scratch off EDI Files. -Create and execute test cases and scenarios.- Knowledge of the Exchange, Commercial Group, and Medicaid lines of business.

Working in both the Enrollment and Sales Departments. Enrollment:Oversee the daily operations of Enrollment and Reconciliation team. Subject Matter Expert for Marketplace Exchange Enrollment. Improve process, train, test, and creat P&Ps for department. Sales: Work with external parties to onboard Producers, Agencies, and FMO/MGA/GAs. Obtaining all required documents and assigning within the department for process. Assist external parties in training for Marketplace, Group, and Medicare LOB. Work with IT to improve systems and automate manual process including testing, production, training, and writing policies. Serves as the department Analyst pulling and analyzing reporting measures in relation to Sales Leads, Membership, Location, Plans, and Producer reviews.

Lead the exchange enrollment department in daily operations. Operations include process of enrollment individual and small business groups. Review automatic import of enrollment files to report on technical issues that occur and help to improve overall import process. Internal set up of small business groups. Subject matter expert for Market Place Exchange related enrollment question including compliance standers for CMS. Lead of HICS casework process and review. Lead of monthly reconciliation audit. Prepare training materials such as test work and training binders to both existing and new team members. Process and implementation of all exchange enrollment, HICS, and Reconciliation policies and procedures. Auditing of all enrollment processes on a daily bases. Research current department errors occurring to better the enrollment process as a whole as well as work with IT, compliance, accounting, and various other departments to better operation processes for Market Place Exchange line of Business.

Processing of enrollment and dis-enrollment of members, answering eligibility questions, daily review of 834 file imported, Enrollment Data Reconciliation, implementation of policies and procedures for the exchange department, creating training manual and processes for new the exchange reps.

Greeting patiens, daily review of eligibility, collection of co-pay/co-insurance, scheduling return appointments for patients, and writing of dispute letters for patients with denied medical claims.

Louisiana Medicaid, Medicare, private insurance, State and self pay programs. Verified insurance, billing and accounts receivable for self pay. Audited medicaid, medicare, and private insurance billing. Order and track monthly medical supplies.