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Fallon Health Enrollment & Billing Operations Representative III in Worcester, Massachusetts


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.

Brief Summary of Purpose:

Under the direction of the Supervisor or Manager, the Enrollment & Billing Operations Representative III 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. Problems not clearly defined by written directives or instructions are reviewed with the Enrollment & Billing Operations Supervisor or Enrollment & Billing Operations Manager to determine course of action.

The Enrollment & Billing Operations Representative III 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 supervisor/manager. Responsible for ensuring the integrity of information being entered & maintained within the QNXT system. This includes ensure the accuracy of premium invoices prior to dispersion to the Finance Team and external print vendor. 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 Enrollment & Billing Operations Representative III is considered the main resource person for all Regulatory staff for issues regarding the eligibility and reconciliation processes and will assist the Management team with projects and/or daily workload for all regulatory products. Responsible to reconcile the accuracy of payment file received from online premium payment vendor. Responsible for maintaining accuracy of Regulatory receivables based on dollars billed and received from customers, State and Federal agencies. 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 the business need. Initiates self-development via available company and industry educational opportunities

The Enrollment & Billing Operations Representative III is responsible for enrollment and billing maintenance, adhering to daily, weekly, and monthly schedules and administrative related tasks.


Job Responsibilitie s:

Enrollment Maintenance, Maintaining Receivables, & Learning/Development:

  • Provides knowledgeable response to internal and external customer inquiries and concerns regarding enrollment and billing including, but not limited to, qualifying events, policies and procedures, ID cards, letter correspondence (including Outbound Education and Verification), selection of primary care physician, premium invoices, payment inquiries and general eligibility and financial maintenance.

  • Enters and maintains premium rates as provided by Underwriting and Regulatory Affairs (including Low Income Subsidy and Late Enrollment Penalties)

  • Reconciles membership and billing reports as required by CMS, MassHealth and Employer groups (both automated and manual) to ensure accuracy of information.

  • 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 Regulatory Affairs, as needed.

  • Reports back all members who fit the criteria per the Medicaid requiment for TPL, NOB, address and rating category changes.

  • Maintains current inventory and timely closure of all assigned issues and workload.

  • Processes all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily.

  • Displays initiative to assist Supervisor or Manager in balancing workload with co-workers as the flow of work varies.

  • Maintains active and consistent availability on the phone system, as scheduled, for all lines of business both Commercial and Regulatory.

  • Partners with other Operations departments to maximize the efficiency of shared work.

  • Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations

  • Prepare documented payment plans as the request of customers and presents to Management for approval

  • Prioritizes daily and weekly work

  • Collects premium for employer groups and individual members; including but not limited to written correspondence as well as collection calling for delinquent accounts receivables.

  • Imposes late notices and cancellations on delinquent accounts. Prepares balance forward notification and requests for payment history.

  • Prepares and posts payments and adjustments as necessary.

  • Works daily/monthly reports which identify potential problems, including the daily Transaction Reply Report (TRR) from CMS

  • Determines allowance for bad debt.

  • Calculates 5500 Schedule A/C information for Medicare employer groups.

  • Responsible for maintaining professional relationships with customers/vendors; including resolving identified discrepancies in a timely manner

  • Responsible for ensuring timely and thorough eligibility and premium audit procedures are in place and being performed through direct performance. Ensures that department turnaround times and quality standards are met.

  • Responsible for preparing and communicating eligibility and premium decisions reviewed by the Eligibility Review Committee.

  • 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 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

  • Completes other tasks as assigned.

Administrative Tasks

  • Trains new hires and existing staff according to needs

  • Creates/maintaines desk top procedures and P & P’s

  • Serves as resource to other areas for Medicaid questions/isssues

  • Assists Management team on audit responses and/or site visits

  • Distributes 5500 Schedule A/C requests to staff as appropriate

  • Maintains ACH and CC information, including renewals, returns, and proper notification of processing issues and problem resolutions. Processes monthly payment files.

  • Generates automated monthly ACH and Credit Card payment processing requests and postings.

  • Processes ‘Release Batches ’ QNXT batch completions. 

  • Receives and processes daily Lockbox payment file, Credit Card and ACH batches.

  • Distributes/monitors ACH, CC, wire, returns, and payment batches for posting by staff. Maintains/monitors completion of wire report shared with Finance on a daily basis.

  • Responsible for all month end reporting; including but not limited to Accounts Receivable Summary, Aged Trial Balance, Credit and balance forward reporting.

  • Participates in departmental and company-wide process improvement projects, training, 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; including adjustment approval and letter verification, 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.

  • Assists with day to day operations of Billing Operations, assuming responsibility in the absence of the Supervisor and/or Manager.



High School diploma required; Bachelor’s Degree preferred




5 plus years’ experience in an office environment, preferably in health care and/or managed care system

Resources :

  • Proficiency in or ability to learn Microsoft products and Fallon’s core systems and Vendor’s systems

Competencies :

  • Adaptability

  • Analytical ability

  • Aptitude towards mathematical fundamentals

  • Approachability

  • Demonstrate commitment to Fallon Health’s mission, values and vision

  • Proficient in data entry

Independent Action:

  • Meet deadlines with accuracy; time management

  • Prioritize daily and weekly work

  • Resolve/Escalate issues in a timely manner

  • Ability to change priorities and assignments and maintain productivity

  • Personal accountability/self-motivatedDocument and learn from mistakes and training

  • Problem Solving/Customer Focus

  • Builds Relationships/Contributes to Team Performance

  • Focus Upon Quality/Attention to Detail

  • Organizational 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 weeks ago (9/22/2022 4:12 PM)

Job ID 7041

# Positions 1

Category Enrollment & Billing