Government Programs Eligibility Specialist

Overview

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Summary

Responsible for working with pre-enrollees, participants, caregivers, staff and external regulatory staff (such as Mass Health) and NaviCare NHC pre-enrollees to assure that enrollment in the Medicare and Medicaid systems is accomplished accurately and efficiently with appropriate information entered in the FCHP systems. Also, responsible to ensure recertifications are submitted timely and ensure MassHealth has processed. Will interact with FCHP corporate staff as well as NC and SE staff to produce defined reports. Acts as administrative support person to non adult day health center personnel as needed.

Responsibilities

Primary job responsibilities:

• Obtains information necessary from enrollees/caregivers to process Medicare/Medicaid enrollments.
• Coordinates application processes to assure required timeframes and desired outcomes are met.
• Communicates appropriate information to NC and SE staff in a timely manner.
• Communicates information to appropriate FCHP departments.
• Reviews information in QNXT, MMIS, Nextgen and CaseNet and other systems to assure accuracy.
• Interacts with Social Worker/GSSC’s/Navigators and other staff to assure that information is always up-to-date and accurate.
• Prepares and submits appropriate long-term care change forms as needed.
• Completes Medicare, Medicaid and private pay reconciliations in conjunction with FCHP staff.
• Compiles Medicare/Medicaid enrollment data as needed for reports.
• Implements disenrollment proceedures.
• Answers marketing telephone line as assigned.
• Provides administrative support as assigned such as telephone back-up, schedule management, ordering supplies, data entry and document preparation and management.
  
  

Qualifications

Education: High School graduate. Associate or Bachelor’s degree desirable.

Experience

• At least 2 years’ experience working in a geriatric or senior service setting.
• Knowledge of Medicare and Medicaid eligibility requirements highly desirable.
• Customer service and strong computer experience required.
• Physical health sufficient to meet the ergonomic standards and demands of the position.
• Additional performance requirements: Excellent verbal and written communication skills.
• Ability to manage a process to completion with minimal supervision.
• Functional command of Microsoft Office software. Knowledge of IDX helpful.
  
  

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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