APPEALS ISSUE RESOLUTION MANAGER

Executive Service

Appeals Issue Resolution ManagerDivision of TennCareMember ServicesNashville, TNMinimum Monthly Salary: $5,050/monthTennCare compensation is equitable and will be based on education and experience for a qualified candidate in accordance with Department of Human Resources (DOHR) policy.Closing Date: 12/16/2024

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.

This position requires a 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 an Appeals Issue Resolution Manager in the Appeals Operation Group within Member Services. They will work under the immediate supervision of the TennCare Eligibility Appeals Director. The Appeals Issue Resolution Manager will manage a team of Program Coordinators and Contracted Legal Assistants. This position will be responsible for providing support and guidance to the Program Coordinators and Contracted Temporary Resources on matters relating to Medicaid rules, regulations, policies and procedures. The Appeals Issue Resolution Manager will monitor, audit, and provide guidance to the Program Coordinators and Contracted Temporary Resources on the quality and performance of the resolution appeals workload. Additionally, this position will ensure that the Program Coordinators and Contracted Temporary Resources provide excellent customer service to both internal and external stakeholders. Finally, the Appeals Issue Resolution Manager will work collaboratively and proactively with the TennCare Eligibility Director to identify areas of concern and create continuous quality and process improvement plans.

Key Responsibilities:

• Supervise a team of TennCare Program Coordinators and other levels of staff
• Ensure all appeals are processed within the designed time frame given by monitoring, assessing and addressing unit's overall performance.
• Conduct regularly scheduled staff meetings to provide timely information regarding processes, initiatives, directives, and training opportunities, as well as discuss staff ideas for continuous work process improvement.
• Acquire and maintain a thorough understanding of Medicaid statutes, regulations and policies.
• Effectively communicate with, and provide assistance to, colleagues and TennCare members and applicants as needed.
• Identify areas of opportunity and provide effective problem-solving techniques to ensure that the areas of opportunity are resolved in a positive manner
• Utilize Edison to monitor leave balances, approve/deny leave requests and approving payable time
• Utilize the SMART formula to evaluate/rate employee performance throughout the performance review cycle
• Build team morale to ensure staff have a positive and inclusive work environment; which leads to higher job satisfaction, and results in greater team efficiencies and effectiveness

Minimum Qualifications:

Education and Experience: Graduation from an accredited college or university with a bachelor's degree and experience equivalent to five years of professional level experience interpreting policy or procedural provisions for a TennCare, Medicaid, managed Care, or other related health insurance organization, of which two years must include drafting contractual requirements, developing rules and regulations, or supervising staff who deal with health insurance.

Substitution of Experience for Education: Five years of full-time work as a Managed Care Specialist, Managed Care Program Mgr, and/or Managed Care Division Director with the State of Tennessee, of which one year must be at the Managed Care Specialist 3 or higher level.

Necessary Special Qualifications: None.

Examination Method: Education and Experience, 100%, for Preferred Service positions. For Executive Service Positions, Minimum Qualifications, Necessary Special Qualifications, and Examination Method are determined by the appointing authority.

Desirable Qualifications:

• Graduation from an accredited college or university with a bachelor's degree and/or experience equivalent to five years of professional level experience interpreting policy or procedural provisions for a TennCare, Medicaid, Managed Care, or other related health insurance organization, or supervising professional staff who deal with health insurance
• Ability to adapt to changing priorities and deadlines
• Ability to foster and maintain cohesive working relationships
• Ability to interpret and execute policies and procedures -Ability to exercise sound judgment
• Ability to develop direct reports
• Advanced organizational skills, including the ability to prioritize, multi-task and manage workload to meet specific timeframes and deadlines
• Ability to identify the developmental needs of others and coaches, mentors, or otherwise helps others to improve their knowledge or skills -Excellent 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.