Medicaid Eligibility Specialist: Impactful Health Plan Work

Fallon Health; Massachusetts; Presencial; USD 30.000 - 42.000; Jornada completa

Descripción de la vacante

Fallon Health in Worcester, MA is seeking a Medicaid Eligibility Specialist to support enrollment, eligibility maintenance, and premium billing with a focus on accuracy and CMS compliance. The role involves handling Navicare/Summit ElderCare pre-enrollees, recertifications, and coordination with multiple internal departments.

The position requires strong communication, data integrity, and the ability to work in a fast-paced setting while maintaining attention to detail and deadlines.

Formación

• 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.
• Knowledge of Medicare and Medicaid eligibility requirements highly desirable.

Responsabilidades

• Obtains information necessary from potential participants as well as enrollees/caregivers to process Medicaid enrollments.
• Coordinates application processes to assure required timeframes and desired outcomes are met.
• Communicates appropriate information to NC and SE staff in a timely manner.
• Communicates information to appropriate Fallon Health departments.
• Reviews information in QNXT, MMIS, Nextgen and Alchemy and other systems to assure accuracy.
• Interacts with Social Workers/GSSC's/Navigators and other staff to assure that information is always up-to-date and accurate.
• Prepares and submits appropriate long-term care change forms as needed.
• Completes Medicare, Medicaid and private pay reconciliations in conjunction with Fallon Health staff.
• Compiles Medicare/Medicaid enrollment data as needed for reports.
• Timely follow up with potential participants, enrollees/caregivers regarding financial requirements for MassHealth eligibility.
• Provides administrative support as needed assisting with triaging out cases, case back up when needed, saving and scanning MDS's for Summit Elder and etc.
• Other tasks as needed within the department.
• Reconciles membership and billing reports as required by CMS, MassHealth and Health Connector (both automated and manual) to ensure accuracy of information.
• Communicate professionally to resolve discrepancies. Maintains the accuracy and integrity of the eligibility and premium tasks (including working data integrity reports on a daily basis).
• Reports back all members who fit the criteria per the Medicaid requirement for TPL, NOB, Address, and rating category changes.
• Maintains current inventory and timely closure of all assigned issues and workload.
• Process all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily.
• Process all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily.
• 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.

Conocimientos

Analytical skills

Communication skills

Organizational skills

Problem solving

Time management

Educación

High School diploma

Bachelor's degree preferred

Herramientas

MS Excel

MS Word

MS Access

Descripción del empleo

Fallon Health in Worcester, MA is seeking a Medicaid Eligibility Specialist to support enrollment, eligibility maintenance, and premium billing with a focus on accuracy and CMS compliance. The role involves handling Navicare/Summit ElderCare pre-enrollees, recertifications, and coordination with multiple internal departments.

The position requires strong communication, data integrity, and the ability to work in a fast-paced setting while maintaining attention to detail and deadlines.