Medicaid Eligibility Specialist

Fallon Health•Worcester, MA

About The Position

Under the direction of the Manager and/or Senior Medicaid Eligibility Specialist, the Medicaid Eligibility Specialist supports Fallon Health’s mission and provides accurate, timely eligibility, enrollment, and premium billing information. The role enters and maintains enrollee data for MassHealth, NaviCare, Summit Elder Care, and future regulatory products in Fallon Health’s core systems, documents information for tracking, follows applicable service-level agreements, and complies with CMS and EOHHS regulations. The specialist escalates concerns appropriately and follows issues through to resolution; unclear matters are reviewed with a supervisor or manager. The position works with NaviCare or Summit Elder Care pre-enrollees, participants, caregivers, staff, and external regulatory staff to support accurate and efficient enrollment. It ensures timely recertification submissions and confirms MassHealth processing, including long-term care conversions for Summit Elder Care. The specialist collaborates with internal departments and external customers, maintains data integrity, supports premium billing and receivables reconciliation, and identifies potential process improvements. The work requires independent judgment, attention to confidential information, strong communication and organizational abilities, multitasking, and flexibility as business needs and job functions change. The role also performs enrollment and eligibility maintenance, customer-data processing, reconciliations, reporting, administrative support, and related tasks according to daily, weekly, and monthly schedules. Compensation is $26.00 per hour; final compensation depends on the candidate’s experience, skills, and fit with the role.

Requirements

High school diploma required.
At least 4 years of experience in an office environment; healthcare or managed-care experience preferred.
Strong analytical and problem-solving skills.
Aptitude for mathematical fundamentals.
Flexibility in a fast-paced environment.
Excellent organizational and time-management skills.
Strong focus on quality and performance results.
Systems knowledge, including MS Excel, MS Word, and MS Access.
Effective written and verbal communication skills, including telephone communication.
Ability to build relationships and contribute to team performance.
Ability to adhere to DOI, state, and federal guidelines.
Ability to work with confidential customer information and follow plan policies, protocols, and procedures.
Ability to multitask, take accountability, follow through on issue resolution, and exercise independent judgment.

Nice To Haves

Bachelor’s degree preferred.
Healthcare and/or managed-care office experience preferred.
Knowledge of Medicare and Medicaid eligibility requirements highly desirable.

Responsibilities

Obtain information from potential participants, enrollees, and caregivers to process Medicaid enrollments.
Coordinate application processes to meet required timeframes and desired outcomes.
Communicate timely and appropriate information to NaviCare and Summit Elder Care staff and relevant Fallon Health departments.
Review information in QNXT, MMIS, Nextgen, Alchemy, and other systems for accuracy.
Work with social workers, GSSC’s, navigators, and other staff to keep information current and accurate.
Prepare and submit long-term care change forms as needed.
Complete Medicare, Medicaid, and private-pay reconciliations with Fallon Health staff.
Compile Medicare and Medicaid enrollment data for reports as needed.
Follow up with potential participants, enrollees, and caregivers regarding MassHealth financial eligibility requirements.
Provide administrative support, including case triage and backup, and saving and scanning MDS’s for Summit Elder Care.
Reconcile membership and billing reports required by CMS, MassHealth, and Health Connector, using automated and manual processes.
Resolve discrepancies professionally and maintain accurate eligibility and premium records, including working daily data-integrity reports.
Report members meeting Medicaid criteria for TPL, NOB, address, and rating-category changes.
Maintain assigned inventory and close issues and workloads in a timely manner; escalate inventory backlogs daily.
Process customer-data transactions accurately and on time.
Meet internal and external deadlines and comply with CMS and EOHHS regulations.
Prioritize daily and weekly work and maintain professional relationships with customers and vendors, resolving discrepancies promptly.
Keep enrollment and billing records current and accurate, meeting or exceeding corporate and departmental turnaround standards.
Maintain accurate, up-to-date primary care physician assignments in the core system, using data-integrity reports and coordinating with relevant Fallon Health departments.
Represent Fallon Health professionally during in-person eligibility and premium inquiries.
Assist with core-system upgrade testing.
Create and maintain desk procedures and policies and procedures.
Participate in departmental and company-wide process-improvement projects, training, upgrade testing, and team meetings as assigned.
Work department returned mail and maintain daily and monthly productivity records for corporate and departmental dashboards.
Perform other assigned duties and administrative tasks in response to department goals and changing priorities.
Perform functions necessary to maintain accurate subsidiary accounts receivable and premium bills; analyze and reconcile receivables for commercial and regulatory products, identify payment problems, and apply the delinquency process as appropriate.
Review contractual terms and conditions to ensure payments meet contractual requirements.
Handle confidential customer information and follow plan policies, protocols, and procedures.
Recommend process improvements to the supervisor or manager and pursue self-development through available company and industry educational opportunities.