Job Title: Manager, Enrollment & Billing Reconciliation (ACA SME)

About the Job:

Company Description

Antidote Health believes healthcare is a basic human right. Our mission is to redefine healthcare by providing affordable, high-quality, accessible care and insurance products. We offer telehealth services and ACA-compliant health insurance plans in Ohio and Arizona, with plans to expand into additional states. Our "virtual-first" approach integrates with in-person care and features $0 Antidote virtual provider visits, low-to-no copay for in-person visits, and $0 medication benefits. If you are an experienced, mission-driven team member who can flex and adapt to the shifting circumstances of a growth-stage startup and are passionate about care quality, lowering healthcare costs, and improving health and financial outcomes for members, Antidote has a great opportunity.

Role Description

We are seeking a seasoned and strategic Manager of Enrollment & Billing to serve as our Subject Matter Expert (SME) for ACA Marketplace operations. This role provides leadership and direction for our end-to-end enrollment and billing processes, ensuring efficiency, accuracy, and compliance with all company and regulatory requirements.

Key Responsibilities:

Strategic Leadership & Vision:

• Develop and execute a long-term strategy for ACA-related enrollment and reconciliation activities across individual and family product lines and small-group product lines.
• Accountable for billing-related financial operations, including premium revenue integrity, subsidy accuracy, and reduction of revenue leakage.
• Transform binder payment, effectuation, and reconciliation data into actionable business intelligence to inform strategic decisions regarding member services, network management, and financial planning.

Operational & Process Excellence:

• Oversee the OEP and SEP enrollment and billing lifecycle, ensuring the timely and accurate processing of new enrollments, renewals, terminations, premium billing, and payment reconciliation, including the reconciliation of all EDI 820 files for premium subsidies
• Conduct comprehensive reviews of end-to-end workflows to identify and implement opportunities for automation, process streamlining, and risk reduction, and maintain audit-ready documentation for all ACA enrollment and billing processes. Lead incident response, root cause analysis, and corrective action execution for CMS file failures, reconciliation discrepancies, billing issues, and payment gaps.
• Establish, monitor, and report on key performance indicators (KPIs) to ensure process integrity, timeliness, and accuracy.
• Coordinate with vendors and partners to ensure correct eligibility is timely propagated to systems for claims management, PBM, dental, vision, UM, CM, subrogation, etc.
• Ensure the correctness of eligibility and billing information in member communications such as member ID cards, welcome packets, and invoices.

Technical & Systems Mastery:

• Act as the foremost technical expert on CMS data exchange files and processes, including 834 & 820 transactions, Daily Translation Reply Report (DTRR), RCNI/RCNO, MMR, and pre-audit files.
• Collaborate with IT and development teams to enhance our proprietary enrollment platform, serving as a key business stakeholder within an Agile development framework.
• Compliance, Risk & Audit Management:
• Interpret, translate and design controls that ensure compliance with complex CMS and state-based exchange eligibility rules and guidance into clear, actionable platform and operations requirements for the health plan.
• Proactively identify potential compliance risks related to enrollment data, subsidy management (APTC/CSR), income verification, and Special Enrollment Period (SEP) eligibility.
• Lead all enrollment audit engagements and reporting, including for risk adjustment baseline filing, ensuring accurate and timely responses, and develop and implement corrective action plans to address audit findings.

Billing Operations & Revenue Management:

• Oversee the entire billing and collections lifecycle within the billing system, ensuring accurate and timely premium invoicing, payment processing, credit, and refunds.
• Manage and optimize all aspects of Accounts Receivable (AR), including AR aging, unapplied cash, and delinquency management.
• Responsible for accurate revenue recognition, month-end close processes, and financial reporting related to premium billing.
• Lead the end-to-end reconciliation of all federal subsidies between our records, the State, and CMS.

Qualifications & Experience:

• Bachelor’s degree in Healthcare Administration, Business, Finance, Information Systems, or a related field, or equivalent relevant work experience.
• 7+ years of progressive experience in a leadership role within a health plan, with a deep focus on government programs, specifically the ACA Marketplace.
• 3+ years of direct leadership experience in a high-volume production environment (e.g., billing, enrollment, claims).
• Demonstrated mastery of CMS enrollment and payment reconciliation processes and an expert-level understanding of all related data files (RCNI, RCNO, MMR, EDI 834, EDI 820, etc.).
• Proven ability to identify, optimize, and streamline business processes to improve efficiency and reduce costs.
• Proven experience defining business requirements for internally developed enrollment platforms.
• Demonstrated ability to lead through ambiguity in fast-growing or transforming organizations.
• Exceptional analytical, problem-solving, and root cause analysis skills.
• Advanced proficiency in Microsoft Excel and experience using at least one data visualization tool (e.g., BI Tool).

What We Offer:

• A unique opportunity to be part of a mission-driven company that is changing the future of healthcare.
• A dynamic and collaborative work environment with a strong sense of community.
• Competitive salary and benefits package.
• The opportunity to make a real impact on the lives of the people we serve.