Enrollment And Billing Operations Representative II

Fallon Community Health Plan Worcester , MA 01601

Posted 2 months ago


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.

Brief summary of purpose:

Under the direction of the Supervisor or Manager, the Enrollment & Billing Operations Representative I supports Fallon Health's mission, vision and values by providing and maintaining timely and accurate enrollment and billing information. Documents pertinent information enabling tracking of group/subscriber/member and eligibility and adheres to internal and external SLA's. With speed, accuracy, and integrity, ensures that enrollee data for Medicare Advantage, Medicare Supplement, NaviCare, Summit Elder Care, Fallon Health Weinberg and any future regulatory products is entered into Fallon Health's core system. Completes work accurately and timely to remain in compliance with DOI, CMS and EOHHS regulations. Appropriately

escalates concerns when necessary and follows issues through to closure. Reviews problems not clearly defined by written directives or instructions with the Enrollment & Billing Operations Representative III, Enrollment & Billing Operations Supervisor, or Enrollment & Billing Operations Manager to determine course of action.

The Enrollment & Billing Operations Representative I collaborates effectively with co-workers and other departments to ensure quality service to our internal and external customers. Maintains a positive approach to issues and concerns as they arise, and works to identify and recommend process improvements to his/her direct supervisor/manager.

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. Reconciles employer group bills to group payment listings or direct pay member bills, and appropriately researches. Reviews monthly Accounts Receivable Summary and Aged Trial Balance to identify problems with payments, etc.

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 the business need. Initiates self-development via available company and industry educational opportunities

Enrollment & Billing Operations Representative is responsible for enrollment and billing maintenance, adhering to daily, weekly and monthly schedules and administrative related tasks.


  • Communicates 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 and premium support to the Sales department or Regulatory Affairs, as needed.

  • Maintains current inventory and timely closure of all assigned issues and workload.

  • Processes all transactions related to customer data in a timely and accurate manner. Escalates inventory backlog daily.

  • Displays initiative to assist Supervisor or Manager in balancing workload with co-workers as the flow of work varies.

  • Maintains active and consistent availability on the phone system, as scheduled, for all lines of business both Commercial and Regulatory.

  • Partners with other Operations departments to maximize the efficiency of shared work.

  • Meets internal/external deadlines and remains in compliance with CMS and EOHHS regulations

  • Prioritizes daily and weekly work

  • Collects premium for employer groups and individual members; including but not limited to written correspondence as well as collection calling for delinquent accounts receivables.

  • Imposes late notices and cancellations on delinquent accounts. Prepares balance forward notification and requests for payment history.

  • Prepares and posts payments and adjustments as necessary.

  • Works daily/monthly reports which identify potential problems, including the daily Transaction Reply Report (TRR) from CMS

  • Determines allowance for bad debt.

  • 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.

  • 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 Provider Relations, Contracting and Account and Provider Configuration.

  • Maintains professional etiquette and positively repres

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Enrollment And Billing Operations Representative II

Fallon Community Health Plan