About us:

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 Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. 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.

Brief summary of purpose:

Under the direction of the Manager’s, the Eligibility and Revenue Operations Representative 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 Medicare Advantage, Medicare Supplement, NaviCare, Summit Elder Care, Fallon Health Weinberg and any future regulatory products is entered into Fallon Health’s core system. Completes work accurately and timely to remain in compliance with DOI, CMS and EOHHS regulations. Appropriately escalates concerns when necessary and follows issues through to closure. Reviews problems not clearly defined by written directives or instructions with the Eligibility and Revenue Operations Coordinator, Senior Financial Support or Manager to determine course of action.

The Eligibility and Revenue Operations Representative collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Interacts with departments such as Accounting, Sales, and Regulatory Affairs. Maintains a positive approach to issues and concerns as they arise and works to identify and recommend process improvements to his/her direct manager. Responsible for ensuring the integrity of information being entered & maintained within the core system (QNXT, TruCare, EOHHS, Trackers, etc) 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. The Eligibility and Revenue Operations Representative will assist the Management team with projects and/or daily workload for all regulatory products. Assist Account & Provider Configuration in working updates needed in sponsor configuration. This is handled through working DI reports.

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 and ensures accuracy of premium bills. Analyze/reconcile receivables balance for Commercial and Regulatory products to identify problems with payments and/or impose the delinquency process. Study the contractual terms and conditions to ensure payments received meet the contractual requirements.

Handles confidential customer information. Knowledgeable of plan policies, protocols, and procedures. 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 business needs. Initiates self-development via available company and industry educational opportunities

The Eligibility and Revenue Operations Representative is responsible for enrollment and billing maintenance, adhering to daily, weekly and monthly schedules and administrative related tasks.

Primary Job Responsibilities:

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 Provider Partners, 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.

Enters and maintains data in the E&B tracker in a timely and accuarte fashion to to be utilized with the required reporting from CMS and EOHHS.

Assists with core system upgrade testing

Assists in creating/maintaining desk top procedures and P&P’s

Assists Management team on audit responses and/or site visits

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

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.

Ensure adherence to documented payment plans

Experience: 

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

Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 25.00 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.