Eligibility Representative

Point32Health • Remote Worker Home Office (MA), MA

12d • $28 - $41 • Hybrid

About The Position

The MassHealth Eligibility Representative will support the MassHealth Eligibility Assistance Program by providing guidance and enrollment assistance to individuals who may be eligible for MassHealth Standard, the Frail Elder Waiver, and/or CommonHealth 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 MassHealth eligibility requirements, Medicare coverage, benefits, and available program options within an assigned territory. The representative will assist individuals in navigating the MassHealth 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 MassHealth Eligibility Representative will assist individuals with MassHealth 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 MassHealth 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.

Requirements

• High school diploma.
• 1-3 years of professional experience.
• Experience conducting community outreach and public presentations is necessary.
• Strong knowledge of Medicaid and Medicare programs, including eligibility requirements and enrollment policies, with experience providing enrollment assistance.
• Ability to work compassionately and efficiently with diverse populations, including the elderly and their caregivers.
• Must have excellent written, oral, and interpersonal communication skills, with strong presentation skills and experience conveying complex information clearly.
• Outstanding customer service skills with a consultative approach.
• Excellent time management, organizational skills, and attention to detail.
• High degree of planning, problem-solving, and good analytical skills.
• Must be able to work independently, collaborate with others, as well as nurture relationships with internal staff and external partners.
• Comfortable working in a fast-paced environment.
• Must be proficient in MS Office applications, Word, PowerPoint, and Excel.
• Bilingual or multi-lingual required.

Nice To Haves

• Active Health Producer license for the state of Massachusetts is a plus.
• Bachelor’s degree in a related field.
• 3-5 years of experience with Public Assistance Programs (i.e., MassHealth; Supplemental Nutrition Assistance Program-SNAP, etc.) and Medicare.
• Experience networking/generating leads preferred.
• Experience in a multicultural environment is a plus.

Responsibilities

• Serve as a MassHealth subject matter expert and stay up to date on eligibility policies and regulations by attending quarterly MassHealth Training Forums and other relevant training sessions.
• Review and interpret new policy updates and communicate changes to the team.
• Support seniors presumed eligible for MassHealth 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 MassHealth Standard.
• Organize and participate in community events to raise awareness about MassHealth, Medicare, and the Home and Community-Based Waiver programs.
• Generate SCO leads to support membership growth by providing enrollment or renewal assistance in the MassHealth, 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 MassHealth redetermination efforts, to prevent members from losing their benefits and ensure continuity of care by serving as a liaison between the enrollment department, clinical team, external ASAPs, and care managers.
• Meet with prospects, members, and caregivers to complete applications or renewal forms, and assist with understanding and navigating the application process, including troubleshooting any issues that arise.
• Follow up to collect required documentation, track application status via the MassHealth Eligibility Verification System (MMIS) or by contacting the MassHealth Enrollment Center (MEC), notify them of approvals, and connect them to our SCO team of experts for enrollment.
• Develop and implement an outreach plan within the assigned territory and provide weekly activity plans and result summaries.
• Maintain thorough documentation in our Customer Relationship Management (CRM) platform for all activities and interactions.
• Provide quality customer service by responding to all inquiries professionally, efficiently, and courteously.
• Represent THP SCO in alignment with company values and departmental Code of Ethics.
• Adhere to company and departmental policies and procedures, including CMS and EOHHS guidelines.
• Ensure 100% compliance with all required certifications, licensing, continued education, policy acknowledgment, and work plan documents within required completion dates.
• Successfully complete annual product training, AHIP certification, and any additional required training or certification.
• Handle complaints and issues, escalating to higher management when necessary.
• Perform other duties and projects as assigned.
• Participate in team meetings and contribute to continuous improvement initiatives.

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED