DIRECTOR OF APPEALS, LONG TERM SERVICES AND SUPPORTS - 74364

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:

Oversee and direct the Long-Term Services and Supports (LTSS) Appeal processes. Ensure LTSS remains compliant with both Federal and State regulations.

Key Responsibilities:

• Supervise a team of nurses and a legal assistant -Maintain strong professional relationships with internal and external customers
• Develop and maintain LTSS Appeal and Audit policies and procedures
• Manage vendor contract deliverables and outcomes to ensure contract requirements and goals are achieved
• Assist in strategic planning and implementation of new program initiatives
• Lead a team to ensure decisions are accurate, timely, and compliant with State and Federal rules
• Create and facilitate level of care and appeals training for contractor
• Analyze initial orders issued by the Administrative Procedures Division and collaborate with the Office of General Counsel to appeal initial orders
• Complete performance evaluations and individual performance plans using the S.M.A.R.T formula
• Coordinate and Collaborate with Managed Care Organizations on challenging cases to ensure proper care for members
• Serve as the expert policy witness for LTSS
• Conduct bi-annual, or as needed, Adverse Action Letter review to ensure letters are clear, concise, and has correct rule citations
• Collect, compile, and analyze data for CMS Quarterly Report
• Assist in the development of policy, rules and contracts for LTSS programs
• Provide feedback to management for TennCare Rule and policy changes
• Function as a reliable and trusted member of the LTSS Operations management team
• Ensure team is competent, trained, and knowledgeable

Minimum Qualifications:

• Bachelor's degree from an accredited college or university in related field (master's degree in health care field preferred - MBA, MPH, MPP, or MHA) AND 3+ years in similar role or in health care management or operations.
• Experience interpreting policy or procedural provisions for a related health insurance or provider organization is preferred.
• Experience in analyzing data and using data to drive performance and expectations.

OR

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

Desirable Qualifications

• Professional level experience interpreting policy or procedural provisions for a TennCare, Medicaid, Managed Care, or other related health insurance organization.
• Strong computer skills including mastery of Microsoft Office applications such as Excel, Access, Word, and Power Point, and the capacity to learn other statistical software applications
• Highly developed written and verbal communication and presentation skills, including technical writing; ability to communicate effectively with technical and non-technical clients in a clear, concise, logical and understandable manner
• Skilled in critical thinking, conducting quality reviews of information, and providing input for system improvement (related to both quality of data and efficiency)
• Demonstrated ability to see projects through to completion with minimal oversight, problem solve in unanticipated situations, manage multiple tasks simultaneously, and adhere to priorities set by supervisor as well as being able to re-prioritize tasks as needed
• Demonstrated capacity to successfully navigate within a fast-paced environment with shifting priorities and varying degrees of ambiguity
• Excellent organizational skills, including the ability to prioritize, multi-task, and manage workload to meet specific timeframes and deadlines
• Flexible and adaptable; ability to adjust plans based on new learning and/or changing program goals

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.