Fallon Health

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Enrollment & Billing Quality Assurance Analyst - Growing Health Insurance Company!!

Enrollment & Billing Quality Assurance Analyst - Growing Health Insurance Company!!

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# 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 of purpose:

Under the direction of the Director of Enrollment & Billing Operations, the Quality Assurance Analyst supports Fallon Health’s mission, vision and values by providing and maintaining timely and accurate enrollment and billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLA’s. With speed, accuracy, and integrity, ensures that enrollee data for all lines of business for Fallon Health is entered into Fallon Health’s core system. Completes work accurately and timely to remain in compliance with internal and external SLAs. Appropriately escalates concerns when necessary and follows issues through to closure. Reviews problems not clearly defined by written directives or instructions with the Enrollment & Billing Operations management team to determine course of action.

The Quality Assurance Analyst collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers, and validates processes are being completed timely and in accordance with our policies and procedures as they pertain to internal audit requirements. Maintains a positive approach to issues and concerns as they arise, and works to identify and recommend process improvements to the Enrollment & Billing leadership team. Through quality control and departmental audits, the Quality Assurance Analyst is responsible for identifying gaps in our procedures as they relate to our internal audit practices, and escalates concerns to the Director of Enrollment & Billing Operations. Must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan to remain within compliance.


Pre-requisites for success in this position include: Strong verbal & written communication skills including demonstrated excellence in telephone communication skills; strong organizational skills, computer skills. Performs all functions necessary to maintain accurate subsidiary accounts receivable, ensures accuracy of premium bills, ensures accuracy of data entry for eligibility, and reviews data integrity to ensure reports are worked appropriately, and through completion. Assists the leadership team to oversee the reconciliations for employer group bills to group payment listings or direct pay member bills are completed timely and in accordance with the approved policies and procedures. Works collaboratively with the leadership team to ensure completion of monthly and yearly subsidiary accounts receivable and premium billing reports.


Handles confidential customer information. Knowledgeable of plan policies, protocols, and procedures. Responsible for edits and updates to our departmental policies, and works closely with Operations Support Services to ensure procedure are up to date. Requires ability to work in a fast-paced environment with multi-disciplined staff. Consistently follows through on issue resolution. Strong multitasking abilities are essential along with taking accountability and understanding job functions can change based upon the business need. Initiates self-development via available company and industry educational opportunities.


Primary Job Responsibilities (Include duties that represent 5% or more of employee’s time)

  • Performs regular review of policies and procedures, working closely with the leadership team to ensure these are up to date and being adhered to.
  • Verifies data entry as it pertains to both Enrollment, Billing and PCPs
  • Performs review of monthly eligibility and billing reconciliations, works closely with the representatives to ensure reconciliations are worked timely and sign off is complete.
  • Communicates professionally to resolve discrepancies. Maintains the accuracy and integrity of the eligibility and premium tasks (including working data integrity reports on a daily basis).
  • Provides all necessary eligibility and premium support to the Sales department or Commercial Affairs, as needed.
  • Maintains current inventory and timely closure of all assigned issues and workload.
  • Works with team to ensure timely and accurate responses provided to customers. Escalate inventory backlog daily.
  • Conducts call quality assurance on a monthly basis to ensure department is adhering to the corporate metrics.
  • Partners with other Operations departments to maximize the efficiency of shared work.
  • Meets internal/external deadlines in compliance with CMS and Division of Insurance rules and regulations.
  • Ensures late notices and cancellations on delinquent accounts are issued to members and groups in accordance to our internal production calendar. Reviews manual letters including balance forward notifications prior to being mailed to customers.
  • Works daily/monthly reports which identify potential problems
  • Works with the leadership team in the development of month account analysis report.
  • Reviews and approves 5500 Schedule A/C information for employer groups.
  • Responsible for ensuring timely and accurate eligibility and premium audit procedures are in place and being performed through direct performance. Ensures that department turnaround times and quality standards are met.
  • Works proactively to ensure the enrollment and billing records are kept current and accurately. Ensures goals and turnaround standards are being met or exceeded based on corporate and departmental metrics.
  • Reviews data integrity reports to ensure PCP assignments are done timely and accurately.
  • Ensures contract and billing objectives are being met.
  • Prepares documentation for internal and external auditors as required
  • Ensures Model Audit Rule (MAR) internal controls and compliance is maintained
  • Maintains professional etiquette and positively represents Fallon Health.
  • Enters and maintains data in the E&B tracker in a timely and accuarte fashion to be utilized for metric reporting purposes
  • Assists with core system upgrade testing
  • Assists leadership team with the creating and maintaining of desk top procedures and P & P’s
  • Assists leadership team on audit responses and/or site visits from internal and external auditors
  • Ensures monthly payment files are processed timely and accurately.
  • In collaboration with leadership team, ensures monthly/yearly requirements are met by the team.
  • Participates in departmental and company-wide process improvement projects, training, testing and team meetings as assigned.
  • Quality control of enrollment and billing processes for accuracy and compliance to established policies and procedures.
  • Responsible for maintaining up to date productivity records on a daily and monthly basis for corporate and departmental dashboards.
  • Provides detailed analyses and explanations of all transactions to Enrollment and Billing Director/Manager and COO as requested
  • Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks.



Associates degree required, Bachelor’s Degree preferred






5 plus years’ experience in an office environment, preferably in health care billing or accounting, and experience in adherence to, internal and external, financial and regulatory audit requirements.