Fallon Health Senior Care Enrollee Services Representative - Health Insurance Company! 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 accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
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.
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 benefits
handling prospect inquires
conducting telephonic enrollment
conducting enrollment verification calls
To serve as a liaison between enrollees and FCHP with their concerns regarding their Medicare/Medicaid benefits, denied claims, referrals, and membership.
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.
Conducts telephonic enrollments according to CMS requirements and ensures that these enrollments are recorded
Conducts outbound enrollment verification calls according to CMS requirements
Handles tasks related to re-determination process for enrollees who lost eligibility for MassHealth Standard benefits
Handles all enrollees’ questions to NaviCare benefits, provider network, MassHealth eligibility and other
Fields inbound calls from prospects interested in NaviCare. Inquires may be received from family member, seniors, and eldercare professionals.
Demonstrates consulted approach to telephone sales.
Utilizes CMS approved scripts as appropriate
Documents information regarding leads in the CRM
Supports the outreach and enrollment teams as a resource
Serves as a subject matter expert in the NaviCare product and benefits.
Responds directly to member inquires and ensures that communication and materials are provided in enrollee’s primary language or through an alternative language device or telephone translation service.
Serves as an expert in handling all types of enrollee inquires related to MassHealth and Medicare benefits as well as all terms of the Senior Care Option (SCO) contract, including the covered benefits listed in the SCO contract (appendix A)
Prepares monthly new enrollee list for the Marketing Unit which is utilized to conduct the new enrollee survey
Handles special projects as assigned by the management team
Adheres to FCHP confidentiality policy
Keep management apprised of any system-wide issues, deficiencies, problems and opportunities for improvement and offer recommendations for solutions.
Education: College degree (B.S. or B.A.) Preferred
Experience: 1-3 years previous professional experience in related position (preferably in health care) 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.
Job ID 5769
# Positions 1
Category Customer Service