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Fallon Health Senior Care Enrollment and Eligibility Lead 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. Apersonalized 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.


The team lead provides guidance and instruction and monitors the daily work for an assigned group to ensure operational business needs are meet and adherence to established policy and procedures. The team lead works under the guidance of the manager/director and raises concerns to the manager to address resource constraints, interpret policy, establish new procedures and resolve conflicts. In addition, this role will perform the work of a Sr. ESR/Sr. Medicaid Coordinator as an individual contributor.


  • Oversees workload of assigned team

  • Collaborates with the manager on the daily workload, current assignments of team members and required adjustments (of staff and assignments) to meet business needs.

  • Ensures team has appropriate resources and highlights areas of need to manager for resolution.

  • Reviews staff schedules (scheduled hours, time off, etc.) with manager to ensure adequate coverage is provided.

  • Raises concerns to the manager regarding issues that may affect the work environment, team or individual performance. Participates in implementing solutions as appropriate.

  • Serves as subject matter resource for the team

  • Acts as a senior resource person/subject matter expert for team members in all areas of the work, including but not limited to: application of appropriate policy and procedures, etc.

  • Assists the team in resolving routine operational issues as they arise. Serves as second level escalation with internal and external customers as necessary to resolve issues.

  • Acts as a point of contact and resource for the team.

  • Assists with complex issues that fall within existing policy and procedures. Escalates to manager when appropriate.

  • Promotes use of established practices and procedures.

  • Participates in training and developing team

  • Participates in the orientation of new staff.

  • Assists with training and mentoring staff on the application of policy and procedures, documentation requirements, best practices, escalation requirements, use of supporting systems/applications, time management skills, etc.

  • Monitors work for efficiency, effectiveness and quality, including conducting audits as requested by the manager.

  • Provides feedback to the manager on team members’ performance – achievement of goals and deliverables and assessment of competencies.

  • Assists the Department Managers with developing and implementing processes and/or procedural improvements or changes.

  • Serves as individual contributor, providing the full spectrum of responsibilities outline for theSr. ESR/Sr. Medicaid Coordinatorincluding but not limited to:

  • Assists with managing of ACD lines

  • Assists with hiring and orientation of new staff

  • Supervise daily activities within the unit which includes:

  • monitoring of work volume for staff person,

  • reassigning work assignments based on the needs

  • Monitors enrollment process to ensure the quality standards are met

  • Conducts Call Quality

  • Reports and analyzes enrollment and call data

  • Provides assistance to the rest of the team, including Medicaid Coordinators and ESRs, regarding job related tasks and acts as a go to person

  • Provide assistance with ad-hoc projects assigned by the manager


Education, Licenses, certification and experience requirements:

Education: Bachelor’s Degree in business, health administration, public health, nursing or related health preferred or * *

License: None required

Certification: None Required *     *

Experience: 3 to 5 years in a management role within a health care setting managing front line call staff. Must have knowledge of regulatory requirements for the health care/appeal industry, excellent written and oral communication skills, excellent organizational and analytical skills, customer service focused, problem-solving ability, and conflict resolution skills.


  • Customer focus

  • Commitment Through Action

  • Contributes to Team Performance

  • Focus Upon Quality

  • Flexible and Adaptive

  • Accountability

  • Leadership

Job ID 5721

# Positions 1

Category Business Development