DSNP MassHealth Eligibility Representative

Job Summary

The position is primarily assisting folks who need MassHealth, assisting them to apply for the first time, renew, or apply for waivers. The ideal candidate has MassHealth application experience and knowledge. Responsible for outreaching to Dual Eligible prospects to assist them with the Medicaid Enrollment process from start to finish, as well as provide Medicare Enrollment guidance. This position is responsible for monitoring and optimizing processes related to MassHealth & Medicare eligibility and enrollment. Will work with existing Dual prospect referrals from the DSNP Sales Reps and external brokers, and conversions will go toward an individual, monthly target.

Essential Functions

• Analyze prospect eligibility related to the Medicaid & Medicare enrollment process.
• Keep up to date on Medicaid and Medicare requirements.
• Work with existing SCO & One Care prospects who have identified a desire to enroll with MGBHP.
• Deliver an exceptional prospect experience via both telephonic and written outreach.
• Assist prospects with the Medicaid & Medicare process by explaining eligibility requirements and applicable forms.
• Collaborate with internal team, specifically Duals Field and Inside Sales Reps, and external brokers to work on pipeline cases.
• Collaborate with external stakeholders if needed.
• Identify operational inefficiencies or process bottlenecks and recommend improvements to enhance workflows and improve enrollment experience.
• Support the creation and maintenance of health plan policies, procedures, and workflows to ensure compliance with regulatory requirements (e.g., CMS, Medicaid, Medicare, state and federal laws).
• Monitor and document member outreaches in the CRM system.

Qualifications

Education: High School Diploma or Equivalent required.

Experience: At least 2-3 years of experience in sales, healthcare, or insurance with a focus on Government Markets required. At least 1-2 years of experience with MassHealth Eligibility and Application Process preferred. Bilingual (Spanish/English) preferred.

Knowledge, Skills, and Abilities

• Familiarity with relevant healthcare regulations, including HIPAA, to ensure compliance and maintain patient confidentiality.
• Familiarity with call center software, customer relationship management systems, and other relevant tools used in a call center environment.
• Familiar with related CMS and State regulatory guidelines related to Medicare Advantage and DSNP enrollment.
• Familiarity with the healthcare industry, hospital operations, and medical terminology.
• Familiarity with Dual Eligible products in Massachusetts.
• Ability to motivate and inspire staff to provide exceptional customer service while maintaining productivity and efficiency.
• Strong problem-solving skills to handle escalated or challenging customer interactions effectively.
• Dedication to providing exceptional customer service and ensuring a positive experience for patients, visitors, and other stakeholders.
• Ability to travel to meet with internal and external partners and prospects.

Working Conditions

Hybrid role with a combination of remote work, local travel, and quarterly in-person team meetings in Somerville, MA. Periodic local travel required to visit customer/client accounts. Candidates must be able to travel locally with reliable transportation. Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time.