Eligibility & Revenue Operations Representative

About us:

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 Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. 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.

Brief summary of purpose:

Under the direction of the Manager's, the Eligibility and Revenue Operations Representative supports Fallon Health's mission, vision and values by providing and maintaining timely and accurate enrollment and billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLA's. With speed, accuracy, and integrity, 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. Appropriately escalates concerns when necessary and follows issues through to closure. Reviews problems not clearly defined by written directives or instructions with the Eligibility and Revenue Operations Coordinator, Senior Financial Support or Manager to determine course of action.

The Eligibility and Revenue Operations Representative collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Interacts with departments such as Accounting, Sales, and Regulatory Affairs. 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) Must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan. The Eligibility and Revenue Operations Representative will assist the Management team with projects and/or daily workload for all regulatory products. Assist Account & Provider Configuration in working updates needed in sponsor configuration. This is handled through working DI reports.

Pre-requisites for success in this position include Strong verbal & written communication skills including demonstrated excellence in telephone communication skills, strong organizational skills, computer skills. Performs all functions necessary to maintain accurate subsidiary accounts receivable and ensures accuracy of premium bills. Analyze/reconcile receivables balance for Commercial and Regulatory products to identify problems with payments and/or impose the delinquency process. Study the contractual terms and conditions to ensure payments received meet the contractual requirements.
Handles confidential customer information. Knowledgeable of plan policies, protocols, and procedures. Requires ability to work in a fast-paced environment with multi-disciplined staff. Consistently follows through on issue resolution. Strong multitasking abilities are essential along with taking accountability and understanding job functions can change based upon business needs. Initiates self-development via available company and industry educational opportunities

The Eligibility and Revenue Operations Representative is responsible for enrollment and billing maintenance, adhering to daily, weekly and monthly schedules and administrative related tasks.

Primary Job Responsibilities:

Provides knowledgeable responses to internal and external customer inquiries and concerns regarding enrollment and billing including, but not limited to, qualifying events, policies and procedures, ID cards, letter correspondence (including Outbound Education and Verification), selection of primary care physician, premium invoices, payment inquiries and general eligibility and financial maintenance.
• Enters and maintains premium rates as provided by Actuarial and Regulatory Affairs (including Low Income Subsidy and Late Enrollment Penalties)
• Reconciles membership and billing reports as required by CMS, MassHealth and Health Connector (both automated and manual) to ensure accuracy of information.
• Communicate professionally to resolve discrepancies. Maintains the accuracy and integrity of the eligibility and premium tasks (including working data integrity reports on a daily basis).
• Provides all necessary eligibility, enrollment and premium support to the Sales Finance, Product owners, and/or Regulatory Affairs, as needed.
• Reports back all members who fit the criteria per the Medicaid requirement for TPL, Address, and rating category changes
• Maintains current inventory and timely closure of all assigned issues and workload.
• Process all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily.
• Maintains active and consistent availability on the phone system, as scheduled, for all lines of business both Commercial and Regulatory.
• Partners with other departments to maximize the efficiency of shared work.
• Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations
• Prepare documented payment plans, and payment extensions at the request of customers and presents to Management for approval
• Prioritizes daily and weekly work
• Prepare 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.
• Prepares and posts adjustments as necessary.
• 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
• Responsible for ensuring timely and thorough eligibility and premium audit procedures are in place and being performed through direct performance. Ensures that department turnaround times and quality standards are met.
• Responsible for preparing and communicating eligibility and premium decisions reviewed by the Eligibility Review Committee.

• Bachelor's Degree preferred
• A verifiable high school diploma or GED is required for all positions at Fallon Health and its affiliates, unless specified otherwise.

N/A

Experience:

4 plus years' experience in an office environment, preferably in health care and/or managed care system

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

Adhere to all DOI, State, and Federal guidelines

Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 25.00 per hour which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.

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.