PACE Enrollment Specialist

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, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's Summit ElderCare is a Program of All-Inclusive Care for the Elderly-PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, 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- in the region.

Brief summary of purpose:

This position requires a high level of organization and efficiency. Activities related to this position include the management of PACE leads through the screening and qualification process, positioning cases for MassHealth application submission and scheduling of the clinical assessment.

Supports Enrollment Process

After initial account executive contact with referral, the enrollment specialist (ENSP) supports next steps toward enrollment, including but not limited to additional education, qualification, document and information gathering. In select cases, the ENSP may be the first contact after the referral is received.
• May coordinate with Account Executives to fulfill site visit requests. If necessary, may meet with Summit ElderCare prospects at a PACE site or in their homes.
• Supports initial financial document gathering, follows through on MassHealth signature pages, and supports resolution of MassHealth Requests for Information (RFIs).
• Supports necessary communication with enrollment nurse team in advance of home visit/assessment.
• As directed, may provide pre-screen coverage for Account Executives during out of office periods. Able to explain the Summit ElderCare program clearly, identify key steps to qualification, and follow through to appropriate next steps.

Manages Prospect Touchpoints

• Supports documentation gathering and submission for final Government Program Enrollment Specialist (GPES) review and MassHealth application submission.
• Follows up on outstanding issues, documents, and directs prospects to appropriate resources as needed.
• Supports resolution of MassHealth Requests for Information.
• Maintains regular touchpoints with prospect families through process as required.

Tracking & Reporting

• Documents and tracks case related activities in the department's CRM database application appropriately.
• Meets deliverables consistently. (e.g.: prospect calls are handled in a timely fashion)

Assessment

• Works with Director to review process effectiveness and integrates adjustments.
• Provides data from CRM database and other resources as requested.
• Seeks advice, training, and coaching from colleagues and manager.
• Acts as a resource for co-workers as required and in support of special projects that tie to program goals

Regulatory Guidelines

• Operates within the marketing and outreach guidelines and regulations provided by Centers for Medicare & Medicaid Services (CMS) and Executive Offices of Health and Human Services (EOHHS).
• When in doubt, asks questions pertaining to compliance or privacy regulations.
• Completes all assigned Fall Health training and educational requirements.

Education, License, certification and experience requirements:

• Education: BS or BA degree and/or comparable experience
• License: Access to reliable transportation in support of outreach activities and/or required home visits.
• Certification: NA

Experience:

• 2+ years of sales experience in healthcare, elder services or a related senior resource environment. Knowledge of customer service, outreach and general marketing principles and practices, is preferred.
• Must be able to work collaboratively with minimal supervision to screen incoming referrals, and guide prospects through appropriate next steps. Must demonstrate confidence as a resource for older adults and their families navigating the PACE enrollment process.
• Knowledge of PACE, Medicare, Medicaid and/or other insurance products is desirable.

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.

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