Fallon Health

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Regulatory Representative - Enrollment

Regulatory Representative - Enrollment

Job ID 
# Positions 
Posted Date 
Enrollment & Billing

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About Fallon Health:         

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


Brief Summary:

With speed, accuracy, and integrity, ensures that enrollee data for Medicare Advantage, Medicare Supplement, NaviCare, Summit Elder Care, Fallon Health Wienberg and Medicaid (and any future regulatory products) is entered into QNXT. Data may be received via an 834 file, TRR, online enrollment center, brokers, or any other distribution channel employed by Fallon Health, submitted either electronically or on paper. All of this needs to be done in an accurate and timely fashion in compliance with CMS and EOHHS regulations.


  • Timely (in accordance with regulatory timelines) and accurate processing of new members and terminations in QNXT and member plan changes.
  • Ensure members are receiving correct letter correspondence, ID cardss and materials  based on transaction type
  • Maintain low income subsidy data and perform functions for annual changes
  • Resolve discrepancies submitted by Relay Health to fallonhealth in a timely manner
  • Individually and collaboratively producing internal and external reports in compliance with CMS and EOHHS.
  • Within internal service level guidelines, resolve member cases identified by Customer Service.
  • Lead or collaborate in weekly or monthly reconcilations as required by MassHealth, CMS, Reed & Associates or fallonhealh customers (Brokers/Employers
  • Individually and collaboratively create and submit membership reconciliations as required by CMS and EOHHS.
  • Identify and document process improvement opportunities.
  • Appropriately process any member demographic changes.
  • When required, participate in the Outbound Education and Verification process with new Medciare Advanatge beneficiaires.
  • If/when appropriate, enter and maintain data in the Batch file in a timely and accuarte fashion.
  • As assigned, address all dsicrepanices as identified via Caremark or Clarity error reporting as well as internal integrity reports.
  • Special projects as assigned. 


Education: High school graduate, some College preferred



  • Adaptability to changing priorities.
  • Excellent keying skills.
  • Good written and verbal communication skills.
  • Attention to details with an eye on quality.
  • Proficient in MS Excel and Word as well as electronic files.
  • Sense of accountability and taking ownership.