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Fallon Health Lead, Government Programs Eligibility Specialist in Worcester, Massachusetts


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. Apersonalized 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.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Brief Summary of Purpose:

Responsible for working with NaviCare NHC pre-enrollees, participants, caregivers, staff and external regulatory staff (such as MassHealth) to assure that enrollment in Medicare, Medicaid and FCHP systems is accomplished accurately and efficiently. Also, responsible to ensure re-certifications are prepared and submitted timely to minimize eligibility disruptions. Produces routine and ad hoc management reports regarding Medicaid processing activity when necessary. Serves as the primary subject matter expert on Medicaid processing issues. Acts as the primary training resource for new Medicaid processing staff. Will interact with FCHP corporate staff as well as NC staff to share data and produce defined reports.


  • Obtains information necessary from enrollees/caregivers to process Medicaid enrollments and recertifications.

  • Interacts with MassHealth staff and other parties such as elder law attorneys to ensure timely MassHealth approvals and recertifications.

  • Coordinates application processes to assure required timeframes and desired outcomes are met.

  • Communicate deadline goals to team members.

  • Serves as a primary subject matter expert on Medicaid eligibility processing activity for FCHP’s coordinated care and coverage programs and supports the maintenance of NC policies and procedures involving Medicaid issues.

  • Serves as a mentor for the team. Motivates team members including communicating team goals.   

  • Communicates appropriate information to NC and other FCHP staff in a timely manner.

  • Produces routine and adhoc reports regarding Medicaid eligibility processing activities.

  • Reviews information in QNXT, MMIS, MAPS, Nextgen, CaseNet and other systems to assure accuracy.   

  • Interacts with Participants, Enrollees, caregivers, 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 FCHP staff.

  • Provides help to management, including hiring and training and keeps management updated on team performance.

  • Supports manager and performs management duties when manager is absent from the office.

  • Answers tem member questions

  • Assists manager with updating department policies and procedures.

  • Performs other duties as assigned by Manager.     


Education: High School graduate. Associate or Bachelor’s degree desirable. *     *

Experience: At least 4 years experience working in a geriatric, senior or human service service setting. Knowledge of Medicare and Medicaid eligibility requirements highly desireable. Customer service and strong computer experience required.


  • Demonstrates commitment to the Fallon Community Health Plan Mission, Values and Vision.

  • Strong interpersonal skills

  • Ability to work independently and manage multiple priorities

  • Strong verbal and written communication skills with English as a primary language.

  • Math skills sufficient to provide preliminary eligibility assessments and to support premium reconciliation efforts.

  • Leadership Skills

  • Customer Service Skills

  • Training Experience

  • Problem Solving Skills

  • Product Knowledge and Health Insurance Experience

  • Ability to work with various computer programs including Microsoft Word, Excel, Scanning systems and State systems such as MMIS, MAPS and secure email.

  • Specific competencies essential to this position:


-Analytical Ability


-Results Oriented

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 weeks ago (1/3/2022 2:50 PM)

Job ID 6678

# Positions 1

Category Medicare Medicaid Programs