Classicare Reconciliation Analyst

GENERAL DESCRIPTION: Responsible for performing the ongoing reconciliation of electronic transactions between the internal systems of the company and the systems of Regulatory Agencies and Delegated Entities, complying with the policies and operational processes. ESSENTIAL FUNCTIONS: •Validates and reconciles membership, electronic transactions, and payment data between systems such as internal systems, the Centers for Medicare and Medicaid Services (CMS), Puerto Rico Health Insurance Administration (ASES) Medicaid, and Delegated Entity systems to comply with regulatory requirements and facilitate the collection of premiums from all policyholders. •Identifies error patterns within company systems, refers involved departments for correction, and reports the reconciliation outcomes to management. •Monitors files from CMS, Pharmacy Benefits Management (PBM), ASES, and Medicaid, and sends necessary files or reports to these entities to meet contractual and regulatory obligations. •Analyzes reconciliation results and reports any discrepancies between the company’s systems, regulatory agencies, and Delegated Entities. Validates the required electronic transactions and submits them to CMS following regulatory standards. •Identifies and corrects discrepancies found during reconciliations, including Membership Reports (MMR), Full Files from CMS and ASES, and Accounts Receivable versus Accounts Payable, among others. Additionally, reconciles and addresses discrepancies noted in error reports generated from electronic transactions related to eligibility files for Delegated Entities. •Assist with the submission and follow-up of corrections to CMS (e.g., Retroactive transactions, State and County Code Changes (SCC). •Prepares statistical reports for business analysis and sends all necessary documentation for retroactive transactions to ensure the collection of every policyholder's premium. •Participate in audits, internal reviews, and the preparation of supporting documentation. •Maintains and updates a master document of regulatory and operational processes such as Out of Area (OFA), Loss of Eligibility, Special Needs Plan, Late Enrollment Penalty (LEP), and Retroactive Processing Contractor (RPC), among others. •Documents all reconciliation activities, including updates made in the systems while maintaining organized audit trails. •Generates reports for internal departments to ensure compliance with operational processes, adheres to established timelines according to policy, and resolves issues referred from internal departments. •Provides support during system upgrades, User Acceptance Testing (UAT), and the implementation of new reconciliation tools, reports, or applications. Additionally, documents all validations performed and conducts Validation Test Reports (VTR) as necessary. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s Degree in Business Administration or related fields. At least two (2) years of experience in data reconciliation and analysis, or related areas, preferably in the Healthcare Insurance industry and Medicare Advantage. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: Not required. Other: Intermediate Excel knowledge and basic Database knowledge. Knowledge in Medicare Advantage is preferred. Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal)