Eligibility & Revenue Operations Representative-Medicare​/Medicaid Billing

Overview

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.

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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, Navi Care, 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, Tru Care, 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…