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SalaryExecutive Service
APPEALS REDETERMINATION SPECIALIST
Division of TennCare
Member Services Division
Nashville, TN
Minimum Monthly Salary $3,958/month
TennCare compensation is equitable and will be based on education and experience for a qualified candidate in accordance with Department of Human Resources (DOHR) policy.
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.
Closing Date: 02/05/2024
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.
How you make a difference in this role:
The Division of TennCare is seeking an Appeals Redetermination Specialist for the Appeals Operations Group within Member Services. The Appeals Redetermination Specialist will be responsible for providing support and guidance on matters relating to Medicaid rules, regulations and policies. The Appeals Redetermination Specialist 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 TennCare Program Coordinator will also work collaboratively with management to identify workflow issues and accomplishments.
Key Responsibilities:
- Receives and reviews appeals for potential resolution within policy guidelines daily. If resolution cannot be found moves the case forward in the appeal continuum timely for hearing.
- Demonstrates attention to detail in researching appeal cases and documenting notes for proper case processing.
- Maintains 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. Utilizes case log to report daily productivity to manager.
- Makes phone calls as needed to verify information with appellant regarding appeal.
- Attends and actively participates in all unit meetings and problem-solving discussions for workflow improvements.
Minimum Qualifications:
Education and Experience:
Graduation from an accredited college or university with a bachelor's degree in a related field (preferred degree in business administration, management, public health or health policy)
OR
Graduation from an accredited college or university with an associate's degree in a related field (preferred degree in business administration, management, public health or health policy) and two (2) years of qualifying professional experience in positions associated with the interpretation and application of policy or executing procedural provisions and/or eligibility within a health, healthcare, or health insurance setting.
Substitution of experience for education:
Experience equivalent to four (4) or more years of qualifying professional experience in in a related field (positions associated with the interpretation and application of policy or executing procedural provisions and/or eligibility within a health, healthcare, or health insurance setting).
- Ability to foster and maintain cohesive working relationships
- Ability to adapt to changing priorities and deadlines
- Ability to exercise sound judgment
- Strong organizational skills necessary, including the ability to prioritize, multitask and manage workload to meet specific timeframes and deadlines
- Advanced writing and communication skills
Desirable Qualifications:
Graduation from an accredited college or university with a bachelor's degree in business administration, management, public health or health policy
Four (4) years of experience within TennCare
Four (4) years of experience within a Medicaid, managed care or healthcare organization.
Pursuant to the State of Tennessee's WorkplaceDiscrimination 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.
