Senior Care Enrollee Services Representative

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 delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. 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.

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Fallon Health is a leader in providing senior care solutions such as Navi Care, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and Mass Health Standard. A personalized primary care team manages and coordinates the Navi Care member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.

The Enrollee Service Representative is responsible:

• To execute the following tasks in accordance with the Senior Care Option (SCO) contract requirements, CMS regulations, NCQA standards, departmental policies and procedures, and other applicable regulatory requirements:

• handling of all enrollees’ inquiries, including but not limited to Medicare and Medicaid benefit handling prospect inquiries.

• To serve as a liaison between enrollees and Fallon Health with their concerns regarding their Medicare/Medicaid benefits, denied claims, referrals, and membership.

• Provides coverage for the Navi Care enrollment ACD line and handles Enrollees inquiries in a timely manner.

• Actively engage in onboarding training to learn essential systems, policies, and procedures. Demonstrate the ability to retain, reference, and successfully utilize key resources (e.g., QNXT, Tru Care, Ring Central, departmental guides) to ensure consistent and accurate job performance.

• Serves as a subject matter expert in the Navi Care product and benefits.

• Demonstrate knowledge of enrollment and disenrollment processes and regulations as outlined in the SCO contract, as it relates to enrollee inquiries and call handling. Handles enrollees inquires in a timely manner and Utilizes CMS approved scripts as appropriate.

• Assists enrollees with inquiries related to Medicare and Medicaid benefits.

• Supports the outreach and enrollment teams as a resource.

• Handles enrollee’s billing issues and presents them to Navi Care Clinical Directors or other internal and external physician reviewers as appropriate.

• Assist contracted providers with pending claims issues.

• Ability to protect high degree of confidential/privileged patient and proprietary business information.

• Ability to function effectively in a fast-paced environment and effectively deal with competing priorities.

• Ability to synthesize all applicable regulatory requirements for NCQA, CMS and SCO contract.

• Adhere to quality standards for call handling, documentation, and off phone work.

Bachelor’s degree or equivalent combination of education and experience.

• 1 – 3 years of previous professional experience in a related position, preferable healthcare.

• Ability to communicate and present information to various levels of personnel.

• Working knowledge of computer programs and software.

• Excellent interpersonal skills, ability to negotiate with customers and remain diplomatic.

In accordance with the Massachusetts Wage Transparency…