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 by maintaining timely and accurate eligibility, enrollment, and premium billing information. The role documents information needed to track groups, subscribers, members, and eligibility; meets internal and external service-level agreements; and enters enrollee data for MassHealth, NaviCare, Summit Elder Care, and other regulatory products into Fallon Health’s core systems. The specialist works accurately and promptly to comply with CMS and EOHHS regulations, escalates concerns appropriately, and follows issues through to resolution. Problems not covered by written directives are reviewed with a supervisor or manager. The specialist works with NaviCare or Summit ElderCare pre-enrollees, participants, caregivers, staff, and external regulatory personnel to ensure accurate and efficient Medicaid enrollment. Responsibilities also include timely recertifications and confirming MassHealth has processed them, as well as handling Long Term Care Conversions for Summit ElderCare. The role collaborates with coworkers and departments such as Accounting, Customer Service, Sales, and Regulatory Affairs, and recommends process improvements to management. The position safeguards the accuracy and integrity of information in core systems, including QNXT, TruCare, and Trackers. It requires sound analysis and independent decision-making in the interests of members and the health plan. The specialist also maintains subsidiary accounts receivable, verifies premium bills, analyzes and reconciles receivables for Commercial and Regulatory products, identifies payment issues or delinquency needs, and checks payments against contractual terms. The role handles confidential customer information and applies plan policies, protocols, and procedures in a fast-paced, multidisciplinary environment. Strong communication, organization, computer, multitasking, and follow-through skills are important. The specialist is accountable for enrollment and eligibility maintenance, scheduled work, and related administrative tasks, and is expected to pursue self-development through available company and industry education opportunities.

Requirements

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

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 appropriate information promptly to NaviCare and Summit ElderCare 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 triaging cases, providing case backup, and saving and scanning MDS documents for Summit ElderCare.
Reconcile membership and billing reports required by CMS, MassHealth, and the Health Connector, using automated and manual processes.
Communicate professionally to resolve discrepancies.
Maintain accurate eligibility and premium tasks, including working data-integrity reports daily.
Report members who meet Medicaid criteria for TPL, NOB, address, and rating-category changes.
Maintain current inventory and close assigned issues and workload promptly.
Process customer-data transactions accurately and on time, and escalate inventory backlogs daily.
Meet internal and external deadlines and comply with CMS and EOHHS regulations.
Prioritize daily and weekly work.
Maintain professional relationships with customers and vendors and resolve discrepancies promptly.
Keep enrollment and billing records current and accurate, and meet or exceed corporate and departmental goals and turnaround standards.
Maintain accurate, current primary care physician assignments in the core system by reviewing data-integrity reports and coordinating with Customer Service, Provider Relations, Contracting, and Account and Provider Configuration.
Represent Fallon Health professionally when meeting customers in person about eligibility and premium inquiries.
Assist with core-system upgrade testing.
Create and maintain desk procedures and policies and procedures documentation.
Participate in departmental and company-wide process-improvement projects, training, upgrade testing, and team meetings as assigned.
Perform other assigned duties to meet department goals and respond to changing priorities, including administrative tasks and returned-mail work.
Maintain daily and monthly productivity records for corporate and departmental dashboards.
Maintain subsidiary accounts receivable and ensure premium bills are accurate.
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 requirements.
Handle confidential customer information and follow plan policies, protocols, and procedures.
Escalate concerns appropriately, follow issues through to closure, and identify and recommend process improvements.
Pursue self-development through available company and industry educational opportunities.