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Maryland, United States
Remote only
Key Responsibilities
· Analyze enrollment and eligibility transactions, files, reports, and data exchanges to identify discrepancies, processing errors, trends, and operational risks.
· Validate member records, research complex enrollment issues, and coordinate timely resolution to protect accurate member outcomes.
· Review, validate, and generate member and group invoices and resolve billing disputes, premium discrepancies, and payment-related issues.
· Perform premium, payment, membership, and account reconciliations; research, document, and resolve identified variances.
· Monitor invoices, payments, adjustments, refunds, financial transactions, and billing outputs to maintain data integrity across systems.
· Analyze large enrollment, billing, payment, membership, and financial data sets to identify trends, anomalies, risks, and improvement opportunities.
· Develop operational reports, dashboards, reconciliations, performance metrics, and actionable insights for leadership and operational partners.
· Partner with business and technology teams on SQL-based queries, automated reporting, data validation, reconciliation, and workflow solutions.
· Support new market implementations, product launches, system conversions, testing, production readiness, and scalable process design.
· Ensure enrollment and billing activities comply with CMS, federal, state, health plan, and organizational requirements.
· Support internal and external audits with accurate documentation, analysis, evidence, and issue resolution.
· Develop and maintain standard operating procedures, process maps, training materials, and implementation documentation.
· Enrollment Reconciliation: Execute monthly CMS enrollment reconciliation for Federally Facilitated Marketplace states, including pre-audit file review, RCNI/RCNO processing, discrepancy research, and enrollment data dispute submission; perform equivalent reconciliation with state-based exchanges (e.g., Georgia Access).
· Payment Reconciliation: Reconcile 820 payment transactions and CMS policy-based payment reports to QNXT membership, ensuring APTC, member premium, and user fee amounts are accurate by member and month.
· Grace Period & Delinquency: Administer binder payment, grace period, delinquency, and non-payment termination processes in accordance with federal and state requirements, including member notices and claims pend coordination.
· Downstream Data Integrity: Ensure enrollment and premium data flow accurately to downstream processes, including EDGE server submissions for risk adjustment, MLR premium reporting, capitation membership, and vendor eligibility files (pharmacy, dental, vision, virtual care).
· Financial Close & Controls: Support Finance month-end close by reconciling premium billed, collected, and earned, APTC receivables, unapplied cash, refunds, and unclaimed property; execute and document key internal controls supporting statutory financial reporting.
· Escalations & Complaints: Resolve escalated member, broker, CMS Complaint Tracking Module (CTM), and state Department of Insurance inquiries within required regulatory timeframes.
· Peak Season Readiness: Lead operational readiness for Open Enrollment, renewals and passive re-enrollment, and Special Enrollment Periods, including volume forecasting and backlog management.
· Vendor Oversight: Monitor delegated enrollment, billing, and payment vendors against contractual service levels and accuracy standards.
· Leadership: Serve as QNXT enrollment and billing subject matter expert; mentor analysts and provide guidance on complex cases.
· Data Privacy: Safeguard member PHI and financial data in compliance with HIPAA and company privacy and security policies.
Salary Range
Now, a little about us …
At Tegria, we bring bold ideas and breakthroughs to improve care, technology, revenue, and operations in ways that move healthcare organizations from patient-centered to human-centered. We are helping healthcare put people first—both patients and those who dedicate their lives to delivering care.
And at the very core of this vital work is our incredibly talented people.
People with different backgrounds who welcome challenge and change. People who listen first, ask hard questions, and make decisions to cultivate a culture of equity and inclusion. People who chase after goals, growth, and generosity. We’re real. We’re nimble, and we believe in our mission to humanize healthcare.
Perks and benefits
Top talent deserves top rewards. We’ve carefully curated a best-in-class benefits package, meant to meet you wherever you are in your life and career.
Your health, holistically. We offer a choice of multiple health and dental plans with nationally recognized networks, as well as vision benefits, a total wellness program, and an employee assistance program for you and your family.
Your financial well-being. We offer competitive wages, retirement savings plans, company-paid disability and life insurance, pre-tax savings opportunities (HSA and/or FSA), and more.
And everything in between. Our lifestyle benefits are unrivaled, including professional development offerings, opportunities for remote work, and our favorite: a generous paid-time-off program, giving you the flexibility to plan a vacation, take time away for illness (or life’s important events), and shift your schedule to accommodate those unexpected curve balls thrown your way.
Tegria is an equal employment opportunity employer and provides equal employment opportunities (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. All qualified candidates are encouraged to apply.
