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Fallon Health Senior Care Enrollee Services Representative 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.

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:

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.


  • Foster Open Communication - Creates an atmosphere in which timely and high quality information flows smoothly between self and others, encourages the open expression of ideas and opinions.

  • Negotiation Skills - Can negotiate skillfully in tough situations with both internal and external groups, can settle differences with minumum noise, can win concessions without damaging relationships, can be both direct and forceful as well as diplomatic, gains trust quickly.

  • Adaptability - Handles day to day work challenges confidently, Is willing and able to adjust to multiple demands, shifting priorities, ambiguity and rapid change, shows resilience in the face of constraints, frustrations, or adversity, demonstrates flexibility

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 (11/22/2021 9:14 AM)

Job ID 6474

# Positions 1

Category Customer Service