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Clever Care Health Plan · 10 hours ago

Manager, Medicare Enrollment and Reconciliation

Huntington Beach, CA

Full-time

Hybrid

Mid, Senior Level

$90K/yr - $110K/yr

4+ years exp

Clever Care Health Plan is one of Southern California’s fastest-growing Medicare Advantage plans, dedicated to making healthcare accessible for underserved communities. The Manager, Medicare Enrollment and Reconciliation will maximize the efficiency and performance of the Enrollment Department, ensuring compliance with Medicare rules and regulations while leading a team to improve operations and address complex issues.

Health Care

H1B Sponsor Likely

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

Qualification

Medicare Advantage expertiseEnrollment reconciliation processesCMS enrollment policyMARx transaction codesRegulatory reporting requirementsMicrosoft Office proficiencyLeadership qualitiesVerbal communicationWritten communicationTeam collaboration

Required

Bachelor's degree or equivalent combination of education and experience

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

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

Preferred

Master's degree a plus

Experience working with Market Prominence is a plus

Company

Clever Care Health Plan

Clever Care Health Plan is a healthcare company that provides health insurance for medicare services.

Founded in 2018

Huntington Beach, California, USA

201-500 employees

https://clevercarehealthplan.com

H1B Sponsorship

Clever Care Health Plan has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (2)

2023 (4)

2022 (3)