Director of Membership Reconciliation - Wipro Digital Operations and Platforms : Job Details

Role: Service Delivery Leader (Membership Reconciliation)

Summary:

We are seeking a Service Delivery Leader (Director of Membership Reconciliation) with expertise in the Affordable Care Act (ACA) Marketplace and Exchange operations. The ideal candidate will have a deep understanding of enrollment, membership operations, and reconciliation processes, including but not limited to 834, 820, RCNO, RCNI, EAPS, HICS, and other CMS and state-specific files. This role requires strong leadership, analytical, and project management skills, and a track record of success in healthcare enrollment reconciliation.

Roles and responsibilities:

• Lead a team responsible for accurate and compliant reconciliation of enrollment and membership data for the ACA Marketplace and Exchange line of business.
• Oversee the reconciliation of 834 and 820 files, RCNO, RCNI, EAPS, HICS, and other relevant CMS files, using innovative solutions to enhance and automate processes.
• Collaborate with IT teams, Project Managers, and Business Partners to develop detailed Business Requirements based on analytic research and Root Cause Analysis.
• Provide leadership in developing metrics, continuous improvement efforts, and managing day-to-day operations related to financial reporting and analysis.
• Design and establish teams and processes for enrollment and payment/subsidy reconciliations with CMS, ensuring regular reporting to finance teams on outstanding accounts receivable and unprocessed cash.
• Utilize data analytics to identify process improvement opportunities and ensure accurate reporting of enrollment and payment/subsidy reconciliation.
• Lead a large team of 200+ individuals, ensuring efficient and effective reconciliation processes in a high-pressure, fast-paced environment.
• Implement change and drive process improvements and operational efficiencies within the reconciliation processes in a matrix environment.
• Collaborate with cross-functional teams and external stakeholders to ensure seamless coordination and communication.
• Drive strategic initiatives to improve reconciliation processes and ensure compliance with regulatory requirements, focusing on high-quality service delivery.

Qualification:

• Bachelor's degree in a relevant field; an advanced degree is preferred.
• Extensive experience in healthcare enrollment reconciliation, specifically within the ACA Marketplace and Exchange line of business.
• Strong understanding of CMS files including 834, 820, RCNO, RCNI, EAPS, HICS, and other relevant reconciliation files.
• Proven leadership and project management skills, with the ability to develop teams and meet strategic objectives.
• Proficiency in data analytics tools and techniques, including predictive analytics, data modeling, and revenue forecasting.
• Experience in managing sensitive and confidential information, producing accurate reports, and presenting findings to executive leadership.
• Excellent communication and collaboration skills, capable of working effectively with cross-functional teams and external stakeholders.
• Demonstrated ability to lead and manage large teams in a high-pressure, fast-paced environment.
• Demonstrated ability to effectuate change and drive process improvements in a matrix environment.