Eligibility Representative

Who We Are Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health.

The Mass Health Eligibility Representative will support the Mass Health Eligibility Assistance Program by providing guidance and enrollment assistance to individuals who may be eligible for Mass Health Standard, the Frail Elder Waiver, and/or Common Health and who may qualify for Tufts Health Plan Senior Care Options (SCO) or One Care. This role is responsible for educating seniors, adults with disabilities, and their caregivers on Mass Health eligibility requirements, Medicare coverage, benefits, and available program options within an assigned territory.

The representative will assist individuals in navigating the Mass Health and Medicare enrollment processes, helping them obtain and maintain the coverage necessary to access healthcare services and qualify for integrated care programs. This position supports membership growth for both SCO and One Care by identifying qualified prospects, generating referrals, and developing a pipeline of potential members. The Mass Health Eligibility Representative will assist individuals with Mass Health applications, provide guidance on Medicare enrollment when needed, and support other eligibility-related processes that facilitate successful enrollment into the program that best meets the member's needs.

The Mass Health Eligibility Representative is accountable for achieving monthly enrollment and lead generation goals and must be able to work independently in a fast-paced environment while effectively serving culturally and linguistically diverse populations and their caregivers.

• Mass Health Expertise and Training:
  • Serve as a Mass Health subject matter expert and stay up to date on eligibility policies and regulations by attending quarterly Mass Health Training Forums and other relevant training sessions.
  • Review and interpret new policy updates and communicate changes to the team.
• Support and Outreach:
  • Support seniors presumed eligible for Mass Health Standard, Medicare, and/or the Home and Community-Based Waiver, referred by internal teams and external brokers.
  • Identify and assist current members aged 64+ who may qualify for these programs.
  • Conduct outreach to community-based organizations and provider groups, delivering presentations on program guidelines, eligibility, and enrollment.
  • Facilitate SCO referrals for those already enrolled in Mass Health Standard.
  • Organize and participate in community events to raise awareness about Mass Health, Medicare, and the Home and Community-Based Waiver programs.
• Enrollment and Renewal Assistance:
  • Generate SCO leads to support membership growth by providing enrollment or renewal assistance in the Mass Health, Medicare, and/or the Home and Community-Based Waiver programs.
  • Communicate with prospects, members, and caregivers by phone or in person to explain eligibility criteria and assess eligibility.
  • Assist Medicaid-only prospects and current members in obtaining Medicare, enhancing their coverage, reducing financial burdens, improving healthcare access, and supporting SCO growth.
  • Support Mass Health redetermination efforts, to prevent members from losing their benefits and ensure continuity…