APPEALS ISSUE RESOLUTION SPECIALIST - 71233

Executive Service

The Division of TennCare is dedicated to providing our employees with a hybrid work environment. All TennCare positions have a combination of work from home and work in the office, which varies by position, department, and business need. You may review the specific expectations with our hiring team.

Background Check: This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.

Who we are and what we do:

TennCare is Tennessee's managed care Medicaid program that provides health insurance coverage to certain groups of low-income individuals such as pregnant women, children, caretaker relatives of young children, older adults, and adults with physical disabilities. TennCare provides coverage for approximately 1.7 million Tennesseans and operates with an annual budget of approximately $14 billion. It is run by the Division of TennCare with oversight and some funding from the Centers for Medicare and Medicaid Services (CMS)

TennCare's mission is to improve the lives of Tennesseans by providing high-quality cost-effective care. To fulfill that purpose, we equip each employee for active participation and empower teams to communicate and worked collaboratively to improve organizational processes in order to make a difference in the lives our members. Because of the positive impact TennCare has on the lives of the most vulnerable Tennesseans, TennCare employees report that their work provides them with a sense of meaning, purpose, and accomplishment. TennCare leadership understands that employees are our most valuable resource and ensures professional and leadership development are a priority for the agency.

Job Overview:

The Division of TennCare is seeking Appeals Issue Resolution Specialist for Appeals Operations Group within Member Services. The Appeals Issue Resolution Specialist will be responsible for providing support and guidance on matters relating to Medicaid rules, regulations, and policies. Additionally, this role will ensure that due process standards are met in Medicaid appeals by the accurate and timely processing of appeals and all appeals related documents. Finally, the Appeals Issue Resolution Specialist will also work collaboratively with management to identify workflow issues and accomplishments.

Key Responsibilities:

• Maintain a high-volume caseload and adhere to the timeliness standard of the AIR appeals while conducting the due process review.
• Assist in the achievement of a high performing and positive work environment that will promote the TennCare Mission.
• Receive and review appeals for potential resolution within policy guidelines daily. If resolution cannot be found, the coordinator moves the case forward in the appeal continuum for hearing.
• Maintain case log to ensure all appeals are worked in the order received and follow up is timely is waiting for response from manager or other department.
• Utilize case log to report daily productivity to manager.
• Demonstrate attention to detail in researching appeal cases and documenting notes for proper case processing.
• Attend and actively participate in all unit meetings and problem-solving discussions for workflow improvements.

Minimum Qualifications:

Graduation from an accredited college or university with a bachelor's degree in a related field (preferred: business administration, management, public health, health policy, paralegal, or legal studies) and 2 years of relevant work experience; equivalent combination of education and experience may be considered.

OR

an equivalent combination of education and work experience may be considered.

Desirable Qualifications:

1. Graduation from an accredited college or university with a bachelor's degree, preferably in business administration, management, public health or health policy
2. Four (4) years of experience within TennCare
3. Four (4) years of experience within a Medicaid, managed care or healthcare organization.
4. Ability to foster and maintain cohesive working relationships
5. Ability to adapt to changing priorities and deadlines
6. Ability to exercise sound judgment
7. Strong organizational skills necessary, including the ability to prioritize, multi-task and manage workload to meet specific timeframes and deadlines
8. Advanced writing and communication skills

Pursuant to the State of Tennessee's Workplace Discrimination and Harassment policy, the State is firmly committed to the principle of fair and equal employment opportunities for its citizens and strives to protect the rights and opportunities of all people to seek, obtain, and hold employment without being subjected to illegal discrimination and harassment in the workplace. It is the State's policy to provide an environment free of discrimination and harassment of an individual because of that person's race, color, national origin, age (40 and over), sex, pregnancy, religion, creed, disability, veteran's status or any other category protected by state and/or federal civil rights laws.