Senior Care Enrollee Services Representative

Fallon Health; Worcester (MA); On-site; USD 26,000 - 36,000; Full time

Job summary

Fallon Health in Worcester, MA seeks an Enrollee Service Representative for NaviCare to handle Medicare/Medicaid inquiries and enrollment-related tasks. You will serve as a liaison between enrollees and Fallon Health, addressing concerns about benefits, denied claims, referrals, and membership with accuracy and empathy.

The role requires a bachelor’s degree and 1–3 years in a related healthcare setting, with strong communication, confidentiality, and problem-solving skills.

Qualifications

• Bachelor’s degree or equivalent combination of education and experience.
• 1–3 years of related healthcare experience.
• Ability to communicate and present information to various levels of personnel.
• Working knowledge of computer programs and software.
• Excellent interpersonal skills and diplomacy.

Responsibilities

• Provides coverage for the NaviCare enrollment ACD line and handles enrollees inquiries promptly.
• Onboard training to learn essential systems, policies, and procedures and use key resources to ensure accuracy.
• Serves as a subject matter expert in the NaviCare product and benefits.
• Demonstrates knowledge of enrollment and disenrollment processes and regulations and uses CMS scripts where appropriate.
• Assists enrollees with inquiries related to Medicare and Medicaid benefits.
• Supports outreach and enrollment teams as a resource.
• Handles enrollees’ billing issues and presents them to Clinical Directors or reviewers as needed.
• Assists contracted providers with pending claims issues.
• Maintains confidentiality of patient and proprietary information; manages competing priorities.

Skills

Interpersonal skills

Communication

Negotiation

Education

Bachelor’s degree or equivalent

Job description

Overview

About Fallon Health:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter, and LinkedIn.

About NaviCare:

Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.

Brief Summary of Purpose:

The Enrollee Service Representative is responsible:

• To execute the following tasks in accordance with the Senior Care Option (SCO) contract requirements, CMS regulations, NCQA standards, departmental policies and procedures, and other applicable regulatory requirements:
  • handling of all enrollees’ inquiries, including but not limited to Medicare and Medicaid benefit handling prospect inquiries.
• To serve as a liaison between enrollees and Fallon Health with their concerns regarding their Medicare/Medicaid benefits, denied claims, referrals, and membership.

Responsibilities

Job Responsibilities:

• Provides coverage for the NaviCare enrollment ACD line and handles Enrollees inquiries in a timely manner.
• Actively engage in onboarding training to learn essential systems, policies, and procedures. Demonstrate the ability to retain, reference, and successfully utilize key resources (e.g., QNXT, TruCare, RingCentral, departmental guides) to ensure consistent and accurate job performance.
• Serves as a subject matter expert in the NaviCare product and benefits.
• Demonstrate knowledge of enrollment and disenrollment processes and regulations as outlined in the SCO contract, as it relates to enrollee inquiries and call handling. Handles enrollees inquires in a timely manner and Utilizes CMS approved scripts as appropriate.
• Assists enrollees with inquiries related to Medicare and Medicaid benefits.
• Supports the outreach and enrollment teams as a resource.
• Handles enrollee’s billing issues and presents them to NaviCare Clinical Directors or other internal and external physician reviewers as appropriate.
• Assist contracted providers with pending claims issues.
• Ability to protect high degree of confidential/privileged patient and proprietary business information.
• Ability to function effectively in a fast-paced environment and effectively deal with competing priorities.
• Ability to synthesize all applicable regulatory requirements for NCQA, CMS and SCO contract.
• Adhere to quality standards for call handling, documentation, and off phone work.

Qualifications

Education:

Bachelor’s degree or equivalent combination of education and experience.

Experience:

• 1 – 3 years of previous professional experience in a related position, preferable healthcare.
• Ability to communicate and present information to various levels of personnel.
• Working knowledge of computer programs and software.
• Excellent interpersonal skills, ability to negotiate with customers and remain diplomatic.

Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $22.50 per hour which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

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.