Medicaid Eligibility Specialist

Fallon Health • Worcester, MA

1d

About The Position

Under the direction of the Manager and/or the Senior Medicaid Eligibility Specialist, the Medicaid Eligibility Specialist supports Fallon Health’s mission, vision and values by providing and maintaining timely and accurate eligibility, enrollment and premium billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLAs. With speed, accuracy, and integrity, ensures that enrollee data for MassHealth, NaviCare, Summit Elder Care and any future regulatory products are entered into Fallon Health’s core system. Completes work accurately and timely to remain in compliance with CMS and EOHHS regulations. Appropriately escalates concerns when necessary and follows issues through to closure. Problems not clearly defined by written directives or instructions are reviewed with the Supervisor or Manager to determine course of action.
Responsible for working either with Navicare or Summit ElderCare pre-enrollees, participants, caregivers, staff and external regulatory staff (such as Mass Health) to assure that enrollment in the Medicaid systems is accomplished accurately and efficiently with appropriate information entered into the Fallon Health systems. Also, responsible to ensure recertifications are submitted timely and ensure MassHealth has processed these recertifications as well as Long Term Care Conversions for Summit ElderCare.
The Medicaid Eligibility Specialist collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Interacts with departments such as Accounting, Customer Service, Sales and Regulatory Affairs. Maintains a positive approach to issues and concerns as they arise and work to identify and recommend process improvements to his/her direct supervisor/manager. Responsible for ensuring the integrity of information being entered & maintained within the core systems (QNXT, TruCare, Trackers, etc). Must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan.
Pre-requisites for success in this position include Strong verbal & written communication skills including demonstrated excellence in telephone communication skills, strong organizational skills, computer skills. Performs all functions necessary to maintain accurate subsidiary accounts receivable and ensures accuracy of premium bills. Analyze/reconcile receivables balance for Commercial and Regulatory products to identify problems with payments and/or impose the delinquency process. Study the contractual terms and conditions to ensure payments received meet the contractual requirements.
Handles confidential customer information. Knowledgeable of plan policies, protocols, and procedures. Requires ability to work in a fast-paced environment with multi-disciplined staff. Consistently follows through on issue resolution. Strong multitasking abilities are essential along with taking accountability and understanding job functions can change based upon business need. Initiates self-development via available company and industry educational opportunities.
The Medicaid Eligibility Specialist is responsible for enrollment and eligibility maintenance, adhering to daily, weekly and monthly schedules and administration tasks.

Requirements

• High School diploma required
• 4 plus years’ experience in an office environment, preferably in health care and/or managed care system
• Strong analytical and problem-solving skills
• Aptitude towards mathematical fundamentals
• Flexibility in a fast-paced environment.
• Excellent Organizational skills/time management
• Strong focus on quality & performance results
• Systems knowledge including but not limited to MS Excel, MS Word, MS Access.
• Ability to effectively communicate, both written and verbal.
• Builds Relationships/contributes to team performance
• Adhere to all DOI, State, and Federal guidelines

Nice To Haves

• bachelor’s degree preferred
• Knowledge of Medicare and Medicaid eligibility requirements highly desireable.

Responsibilities

• Maintains active and consistent availability on the phone system, as scheduled, for all lines of business both Commercial and Regulatory.
• Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations
• Prioritizes daily and weekly work
• Responsible for maintaining professional relationships with customers/vendors; including resolving identified discrepancies in a timely manner
• Works proactively to ensure the enrollment and billing records are kept current and accurate. Ensures goals and turnaround standards are being met or exceeded based on corporate and departmental metrics.
• Responsible for maintaining up to date primary care physician assignments in core system accurately and timely. This is to be completed through review of data integrity reports, and working closely with Customer Service, Provider Relations, Contracting and ---- Account and Provider Configuration.
• Maintains professional etiquette and positively represents Fallon Health when meeting in-person with customers for eligibility and premium related inquiries.
• Assists with core system upgrade testing
• Completes other tasks assigned.
• Creating/maintaining desk top procedures and P&P’s
• Participates in departmental and company-wide process improvement projects, training, upgrade testing and team meetings as assigned.
• Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks.
• Works department returned mail
• Responsible for maintaining up to date productivity records on a daily and monthly basis for corporate and departmental dashboards

Benefits

• 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.

What This Job Offers

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