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Fallon Health Director, Government Programs Operations - Remote/ Flexible! in Worcester, Massachusetts


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 the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org .

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 :

This role supports NaviCare, Summit Eldercare and Medicare operations. With general direction from the Vice President, Medicare and Executive Director, NaviCare, the Director is responsible for the daily operations and performance of the NaviCare Enrollee Services team and Medicaid Coordination team, Inside Sales, and Medicare Sales Operations. The Director works as a key driver in the operations of the 3 Government programs, overseeing reporting and compliance as related to enrollment and eligibility. The Director oversees enrollment into MassHealth for the purposes of enrolling into NaviCare or Summit ElderCare, as well as ongoing MassHealth eligibility through the redetermination process, for the entire NaviCare and Summit ElderCare membership. The Director is also responsible for operations to support the Medicare sales division, inclusive of sales for Medicare Advantage, Medicare Supplement, eHealth, online quoting, Ultra Benefits core system and FCHP’s core system QNXT. Provide sales support and optimization of member retention in all 3 programs.


Job Responsibilities:

  • Direct all functions of enrollment and eligibility for NaviCare, Summit ElderCare and FMP as managed by this team

  • Report on membership, eligibility (including voluntary and involuntary disenrollment), and trends for all 3 products

  • Work across departments to increase efficiencies in the enrollment and eligibility processes, including MassHealth enrollment

  • Manage the retention process within the Enrollee Services team, with the goal of reducing the number of voluntary disenrollment

  • Communicate with EOHHS as needed regarding NaviCare or Summit ElderCare eligibility

  • Act as a subject matter expert on MassHealth, continuously educating oneself on the various facets of Medicaid (SSI-G, redetermination, EAEDC, etc.)

  • Oversee all member services conducted by the teams

  • Work with Service Advisory Committee and others in the organization to address any problem trends, and to improve upon internal processes in order to enrich the member experience

  • Monitor types of issues and resolutions with members, as handled by the Enrollee Services team

  • Oversee the data management, analysis, and reporting of the products

  • Provide analytical and project management to the team on a variety of initiatives that contriubte to the overall sales efforts to grow and retain members.

  • Document, monitor and improve current business processes.

  • Establish frequency for reporting to drive performance accountability for Medicare Sales.

  • Develop reports to measure success of new sales and renewal processing against set metrics and standards.

  • Manage the commission payment structure and reporting.

  • Research and resolve questions raised by affiliated brokers regarding bonus and commission plans

  • Assist Sales Coordinators and Sales Executives with broker related quoting activity

  • Hire, train, manage and develop staff, and implement and manage productivity metrics

  • Define roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts.

  • Hire for, on board, and develop talent

  • Build and structure the team for long-term growth and success.

  • Define performance expectations and goals for staff.

  • Track productivity for the entire team, manage workload, and adjust responsibilities on the team as needed.

  • Monitor staff compliance of federal and state requirements as well as internal FH policies

  • Ensure new enrollments are processed per regulations

  • Ensure enrollment confirmation calls, member services calls, and inbound calls on the ACD sales lines, are conducted per regulations

  • Acts as a subject matter expert within NaviCare regarding CMS and state regulations around SCO/SNP enrollment and eligibility

  • Provide leadership and guidance to ensure compliant and appropriate management of sales channel.

  • Ensure that Medicare sales representatives are in full compliance with state and federal regulatory requirements.

  • Complete audits with all Medicare sales reps to monitor product knowledge and ensure their compliance with all Medicare regulations.



Bachelor’s Degree in business, health administration, public health, or related health insurance required




  • At least 5 years in a management role within a health care setting managing front line staff and leads/supervisors.

  • Knowledge of regulatory requirements for health insurance industry, excellent written and oral communication skills, excellent organizational and analytical skills, customer service focused, strong problem solving, and conflict resolution skills.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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.


Location US-MA-Worcester

Posted Date 2 months ago (8/18/2022 11:19 AM)

Job ID 7001

# Positions 1

Category Other