Eligibility & Revenue Operations Representative

About the role

Fallon Health is a company dedicated to improving health and inspiring hope. We provide equitable, high-quality, and coordinated care to our members, focusing on their needs and experiences. Our mission is to lead the provision of government-sponsored health insurance programs, including Medicare, Medicaid, and PACE.

Responsibilities

• Supports the mission by providing and maintaining timely and accurate enrollment and billing information.
• Documents pertinent information enabling tracking of group/subscriber/member and eligibility.
• Adheres to internal and external Service Level Agreements (SLAs).
• 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.
• Escalates concerns when necessary and follows issues through to closure.
• Collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers.
• Maintains a positive approach to issues and concerns as they arise and works to identify and recommend process improvements to his/her direct manager.
• Responsible for ensuring the integrity of information being entered & maintained within the core system (QNXT, TruCare, EOHHS, Trackers, etc).
• Assists the Management team with projects and/or daily workload for all regulatory products.
• Works with Account & Provider Configuration to work updates needed in sponsor configuration.
• Handles confidential customer information.
• Knowledgeable of plan policies, protocols, and procedures.
• Performs all functions necessary to maintain accurate subsidiary accounts receivable and ensures accuracy of premium bills.
• Analyzes/reconciles receivables balance for Commercial and Regulatory products to identify problems with payments and/or impose the delinquency process.
• Studies the contractual terms and conditions to ensure payments received meet the contractual requirements.
• Prepares documented payment plans, and payment extensions at the request of customers and presents to Management for approval.
• Prioritizes daily and weekly work.
• Prepares balance forward notification and requests for payment history.
• Collects premium for employer groups and individual members, including but not limited to written correspondence as well as collection efforts/calling for delinquent accounts receivables in accordance with State and Federal guidelines.
• Works daily/monthly reports which identify potential problems, including the daily Transaction Reply Report (TRR) from CMS and the daily/monthly compare files for Medicaid product lines.
• 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.
• Ensures that department turnaround times and quality standards are met.
• Prepares and communicates eligibility and premium decisions reviewed by the Eligibility Review Committee.

Qualifications

• Education: Bachelor’s Degree preferred. A verifiable high school diploma or GED is required.
• Experience: 4+ years’ experience in an office environment, preferably in health care and/or managed care system.
• Skills: Strong analytical and problem-solving skills, aptitude towards mathematical fundamentals, flexibility in a fast-paced environment, excellent organizational skills/time management, strong focus on quality & performance results, systems knowledge including but not limited to MS Excel, MS Word, MS Access, ability to effectively communicate, both written and verbal, builds relationships/contributes to team performance, adheres to all DOI, State, and Federal guidelines.

Pay

$25.00 per hour