Eligibility Representative

TAHMO Tufts Associated HMO Inc; Massachusetts; Hybrid; USD 57,000 - 86,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Total rewards program benefits

Job summary

Point32Health seeks a MassHealth Eligibility Representative to guide individuals through MassHealth and Medicare enrollment and renewal processes. You will educate seniors, adults with disabilities, and caregivers about eligibility requirements and program options within an assigned territory, supporting SCO/One Care growth.

You will generate leads, conduct community outreach, and assist with applications while maintaining CRM records and meeting monthly enrollment goals.

Qualifications

• Knowledge of MassHealth and Medicare enrollment policies and procedures.
• Experience providing enrollment assistance and guiding eligibility.
• Ability to communicate clearly with diverse populations.
• Must be able to work independently in a fast-paced environment.
• Fluency in multiple languages is a plus.

Responsibilities

• Serve as MassHealth expert and stay updated on eligibility policies.
• Support seniors and enrolled members with enrollment and renewals.
• Conduct outreach to community organizations and provider groups.
• Facilitate referrals and enrollments for SCO/One Care programs.
• Document activities in CRM and track outcomes.

Skills

Medicaid knowledge

Medicare knowledge

Communication skills

Bilingual

Public outreach

Education

High school diploma

Bachelor’s degree

Tools

MS Office

Excel

Word

PowerPoint

Job description

Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

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.

Job Description

Key Roles and Responsibilities

• MassHealth Expertise and Training:
  • 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 and Outreach:
  • 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.
• Enrollment and Renewal Assistance:
  • 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.
• Planning and Reporting:
  • 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.
• Customer Service and Compliance:
  • 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.
• Other Duties:
  • Perform other duties and projects as assigned.
  • Participate in team meetings and contribute to continuous improvement initiatives.

Qualifications

• Certification and Licensure:
  • Active Health Producer license for the state of Massachusetts is a plus.
• Education:
  • Required (minimum): High school diploma.
  • Preferred: Bachelor’s degree in a related field
• Experience:
  • Required (minimum): 1-3 years of professional experience.
  • Preferred: 3-5 years of experience with Public Assistance Programs (i.e., MassHealth; Supplemental Nutrition Assistance Program-SNAP, etc.) and Medicare.
  • Experience conducting community outreach and public presentations is necessary.
  • Experience networking/generating leads preferred.
• Skill Requirements:
  • 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.
  • Experience in a multicultural environment is a plus.
  • 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.

Working Conditions and Additional Requirements

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond the standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range $27.54 -$41.31

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

• 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

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all

All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.