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Fallon Health Senior Care Enrollee Services Representative - Flexible Remote 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.

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:

The Enrollee Service Representative is responsible:

  • To execute the following tasks in accordance with the Senior Care Option (SCO) contract requirements, CMS regulations, NCQA standards, departmental policies and procedures, and other applicable regulatory requirements:

  • processing of enrollment applications

  • handling of all enrollee inquires, including but not limited to Medicare and Medicaid benefit handling prospect inquires

  • To serve as a liaison between enrollees and FCHP with their concerns regarding their Medicare/Medicaid benefits, denied claims, referrals, and membership.


Job Responsibilities:

  • Provides coverage for the NaviCare enrollment ACD line and handles Enrollees inquiries in a timely manner

  • Serves as a subject matter expert in the NaviCare product and benefits.

  • Processes enrollment applications in accordance with regulatory requirements and departmental policies. Strict adherence to department turn-around time standards. Ensures the enrollment database is maintained on a daily basis.

  • Validates enrollment with the confirmation of receipt of the enrollment (834) transaction.

  • Handles enrollees’ inquires in a timely manner and Utilizes CMS approved scripts as appropriate

  • Assists enrollees with their inquires related to Medicare and Medicaid benefits

  • Supports the outreach and enrollment teams as a resource

  • Handles enrollee’s billing issues and presents them to NaviCare Clinical Directors or other internal and external physician reviewers as appropriate.

  • Assist contracted providers with pended claims issues

  • Ability to protect high degree of confidential/privileged patient and proprietary business information

  • Ability to function effectively in a fast-paced environment and effectively deal with competing priorities

  • Ability to synthesize all applicable regulatory requirements for NCQA, CMS and SCO contract.



Bachelor’s degree or equivalent combination of education and experience


  • Annually, required to pass a product certification exam

  • Annually, required to take the AHIP certification


  • 1 – 3 years of previous professional experience in a related position, preferable healthcare.

  • Ability to communicate and present information to various levels of personnel.

  • Working knowledge of computer programs and software.

  • Excellent interpersonal skills, ability to negotiate with customers and remain diplomatic.

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 4:58 PM)

Job ID 7042

# Positions 1

Category Other