Government Programs Eligibility Specialist

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. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Summary :

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 in 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.

Responsibilities

Primary job 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

Qualifications

Education

High School graduate. Associate or Bachelor's degree desirable.

Experience :

Competencies :

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 : 3 days ago (9 / 19 / 2025 12 : 47 PM)

Job ID : 8096

Positions :

Category : Medicare Medicaid Programs

J-18808-Ljbffr