Medicaid Eligibility Specialist

Overview 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 or purpose: Under the direction of the Manager and/or the Senior Medicaid Eligibility Specialist, the Medicaid Eligibility Specialist support Fallon Health’s mission, vision and values by providing and maintaining timely and accurate eligibility, enrollment and premium billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLAs. With speed, accuracy, and integrity, ensures that enrollee data for MassHealth, NaviCare, Summit Elder Care and any future regulatory products are entered into Fallon Health’s core system. Completes work accurately and timely to remain in compliance with CMS and EOHHS regulations. Appropriately escalates concerns when necessary and follows issues through to closure. Problems not clearly defined by written directives or instructions are reviewed with the Supervisor or Manager to determine course of action. Responsible for working either with Navicare or Summit ElderCare pre-enrollees, participants, caregivers, staff and external regulatory staff (such as Mass Health) to assure that enrollment in the Medicaid systems is accomplished accurately and efficiently with appropriate information entered into the Fallon Health systems. Also, responsible to ensure recertifications are submitted timely and ensure MassHealth has processed these recertifications as well as Long Term Care Conversions for Summit ElderCare. The Medicaid Eligibility Specialist collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Interacts with departments such as Accounting, Customer Service, Sales and Regulatory Affairs. Maintains a positive approach to issues and concerns as they arise and work to identify and recommend process improvements to his/her direct supervisor/manager. Responsible for ensuring the integrity of information being entered & maintained within the core systems (QNXT, TruCare, 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. 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 need. Initiates self-development via available company and industry educational opportunities The Medicaid Eligibility Specialist is responsible for enrollment and eligibility maintenance, adhering to daily, weekly and monthly schedules and administrative related tasks. Responsibilities Obtains information necessary from potential participants as well as enrollees/caregivers to process Medicaid enrollments. Coordinates application processes to assure required timeframes and desired outcomes are met. Communicates appropriate information to NC and SE staff in a timely manner. Communicates information to appropriate Fallon Health departments. Reviews information in QNXT, MMIS, Nextgen and Alchemy and other systems to assure accuracy. Interacts with Social Workers/GSSC’s/Navigators and other staff to assure that information is always up-to-date and accurate. Prepares and submits appropriate long-term care change forms as needed. Completes Medicare, Medicaid and private pay reconciliations in conjunction with Fallon Health staff. Compiles Medicare/Medicaid enrollment data as needed for reports. Timely follow up with potential participants, enrollees/caregivers regarding financial requirements for MassHealth eligibility. Provides administrative support as needed assisting with triaging out cases, case back up when needed, saving and scanning MDS’s for Summit Elder and etc. Other tasks as needed within the department 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). Reports back all members who fit the criteria per the Medicaid requirement for TPL, NOB, 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. Process all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily. Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations Prioritizes daily and weekly work Responsible for maintaining professional relationships with customers/vendors; including resolving identified discrepancies in a timely manner Works proactively to ensure the enrollment and billing records are kept current and accurate. Ensures goals and turnaround standards are being met or exceeded based on corporate and departmental metrics. Responsible for maintaining up to date primary care physician assignments in core system accurately and timely. This is to be completed through review of data integrity reports, and working closely with Customer Service, Provider Relations, Contracting and Account and Provider Configuration. Maintains professional etiquette and positively represents Fallon Health when meeting in-person with customers for eligibility and premium related inquiries. Assists with core system upgrade testing Completes other tasks assigned. Creating/maintaining desk top procedures and P&P’s Participates in departmental and company-wide process improvement projects, training, upgrade testing and team meetings as assigned. Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks. Works department returned mail Responsible for maintaining up to date productivity records on a daily and monthly basis for corporate and departmental dashboards. Qualifications Qualification's requirements Education: High School diploma required; bachelor’s degree preferred License/Certifications: 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 Knowledge of Medicare and Medicaid eligibility requirements highly desireable. Pay Range Disclosure In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 26.00 hourly 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 responsibiliti 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. Location US-MA-Worcester Posted Date 1 day ago (10/26/2026 3:50 PM) Job ID 8546 # Positions 1 Category Medicare Medicaid Programs #J-18808-Ljbffr Fallon Community Health Plan, Inc.