Fallon Health · 16 hours ago
Eligibility & Revenue Operations Representative
Worcester, MA, MA, US
Full-time
Onsite
Mid Level
$25/hr - $25/hr
4+ years expFallon Health is a company that cares, prioritizing their members and delivering high-quality, coordinated care. The Eligibility and Revenue Operations Representative supports the company's mission by maintaining accurate enrollment and billing information, ensuring compliance with regulations, and collaborating with various departments to enhance service quality.
FitnessHealth CareMedical
Responsibilities
Provides knowledgeable responses to internal and external customer inquiries and concerns regarding enrollment and billing including, but not limited to, qualifying events, policies and procedures, ID cards, letter correspondence (including Outbound Education and Verification), selection of primary care physician, premium invoices, payment inquiries and general eligibility and financial maintenance
Enters and maintains premium rates as provided by Actuarial and Regulatory Affairs (including Low Income Subsidy and Late Enrollment Penalties)
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)
Provides all necessary eligibility, enrollment and premium support to the Sales Finance, Product owners, and/or Regulatory Affairs, as needed
Reports back all members who fit the criteria per the Medicaid requirement for TPL, 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
Maintains active and consistent availability on the phone system, as scheduled, for all lines of business both Commercial and Regulatory
Partners with other departments to maximize the efficiency of shared work
Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations
Prepare documented payment plans, and payment extensions at the request of customers and presents to Management for approval
Prioritizes daily and weekly work
Prepare balance forward notification and requests for payment history
Collects premium for employer groups and individual members, including but not limited to written correspondence as well as collection efforts/calling for delinquent accounts receivables in accordance with State and Federal guidelines
Prepares and posts adjustments as necessary
Works daily/monthly reports which identify potential problems, including the daily Transaction Reply Report (TRR) from CMS and the daily/monthly compare files for Medicaid product lines
Calculates 5500 Schedule A/C information for Medicare employer groups
Responsible for maintaining professional relationships with customers/vendors; including resolving identified discrepancies in a timely manner
Responsible for ensuring timely and thorough eligibility and premium audit procedures are in place and being performed through direct performance. Ensures that department turnaround times and quality standards are met
Responsible for preparing and communicating eligibility and premium decisions reviewed by the Eligibility Review Committee
Qualification
Required
A verifiable high school diploma or GED is required for all positions at Fallon Health and its affiliates, unless specified otherwise
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
Preferred
Bachelor's Degree preferred
Company
Fallon Health
Founded in 1977, Fallon Health is a community-focused not-for-profit health care services organization based in Worcester, Massachusetts.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Dorothy Vandette
Manager, CEO Office
Todd Bailey
Senior Vice President, Chief Financial Officer
Recent News
2026-01-09
2025-08-07
2025-06-07
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