PACE Enrollment Specialist

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, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's Summit ElderCare is a Program of All-Inclusive Care for the Elderly-PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, 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- in the region.

Brief summary of purpose

This position requires a high level of organization and efficiency, exceptional listening skills, and the ability to communicate clearly to a variety of audiences.

Primary Job Responsibilities

Supports Enrollment Process

After initial account executive contact with referral, for specific cases, the enrollment specialist (ENSP) supports next steps toward enrollment. This could include additional education, secondary qualification, documents and information gathering.
• In select cases, the ENSP may be the first contact for referral sources and/or prospects, performing initial eligibility screening, gathering case related information, and entering lead into the CRM.
• Communicates the SE program clearly to prospects and their families to ensure a solid understanding. If required, qualifies and triggers appropriate next steps.
• May coordinate with AEs to fulfill site visit requests. If necessary, may meet with SE prospects at a PACE site or in their homes.
• In some cases, supports initial financial document gathering, follows through on MH signature pages, and supports gathering of materials needed for RFIs.
• Supports communication with enrollment nurse team in preparation for home visit/assessment.
• As directed, may provide coverage for AEs and other enrollment specialists, during out of office periods.

Manages Prospect Touchpoints

• Supports documentation gathering and submission for final GPES review and MH application submission.
• Follows up on outstanding issues, documents, and directs prospects to appropriate resources as needed.
• Supports resolution of RFIs
• Maintains regular touchpoints with prospective families through the lead development process as required.

Tracking & Reporting

• Documents and tracks case related activities in the department's CRM application appropriately.
• Consistently meets deliverables (e.g.: prospect calls are managed in a timely fashion)

Assessment

• Works with Director to review process effectiveness and integrate adjustments.
• Provides data from CRM and other resources as requested.
• Seeks advice, training, and coaching from colleagues and managers.
• Acts as a resource for co-workers as required and in support of special projects that tie to program goals.

Regulatory Guidelines

• Operates within the marketing and outreach guidelines and regulations provided by CMS and EOHHS.
• When in doubt, asks questions pertaining to compliance or privacy regulations.
• Completes all assigned FH educational requirements.

Education:

BS or BA degree and/or comparable experience

License:

Possession of a valid Mass. driver's license and reliable transportation for marketing activities and home visits

Experience:

2+ years of sales experience in healthcare, elder services, or a related senior resource environment, including knowledge of customer service, sales, outreach and general marketing principles and practices, is preferred.

Must be able to collaborate with the extended team, with minimal supervision to manage incoming referrals, qualify them appropriately, and guide prospects through appropriate next steps. Must demonstrate proven experience in the role of a resource for older adults and their families in support of navigating the PACE enrollment process.

Knowledge of PACE, Medicare, Medicaid, and/or other insurance products is desirable

Pay Range Disclosure:

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.

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