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Senior Care Enrollee Services Representative

Company: Fallon Community Health Plan
Location: Worcester
Posted on: January 15, 2022

Job Description:

Overview

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. A personalized 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.

Brief summary of purpose:

Enrollee Service Representative is responsible:

* To execute the following tasks in accordance with the Senior Care Option (SCO) contract requirements, CMS regulations, NCQA standards, departmental policies and procedures, and other applicable regulatory requirements:
* processing of enrollment applications
* handling of all enrollee inquires, including but not limited to Medicare and Medicaid benefits
* handling prospect inquires


* To serve as a liaison between enrollees and FCHP with their concerns regarding their Medicare/Medicaid benefits, denied claims, referrals, and membership.

Responsibilities

* Provides coverage for the NaviCare enrollment ACD line and handles Enrollee's inquiries in a timely manner
* Serves as a subject matter expert in the NaviCare product and benefits.
* Processes enrollment applications in accordance with regulatory requirements and departmental policies. Strict adherence to department turn-around time standards. Ensures the enrollment database is maintained daily.
* Validates enrollment with the confirmation of receipt of the enrollment (834) transaction.
* Handles enrollees inquires in a timely manner and Utilizes CMS approved scripts as appropriate
* Assists enrollees with their inquiries related to Medicare and Medicaid benefits
* Supports the outreach and enrollment teams as a resource
* Handles enrollee's billing issues and presents them to NaviCare Clinical Directors or other internal and external physician reviewers as appropriate.
* Assist contracted providers with pended claims issues
* Ability to protect high degree of confidential/privileged patient and proprietary business information
* Ability to function effectively in a fast-paced environment and effectively deal with competing priorities
* Ability to synthesiz

Keywords: Fallon Community Health Plan, Worcester , Senior Care Enrollee Services Representative, Sales , Worcester, Massachusetts

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