APPEALS RESOLUTION SPECIALIST - 66581

Executive Service

APPEALS RESOLUTION SPECIALIST

Division of TennCare

Member Services - Appeals Operations Group (AOG)

Nashville, TN

Salary: Minimum Monthly $4,017.00

Closing Date: 04/14/2025

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 an Appeals Resolution Specialist for the Appeals Operations Group within Member Services. The Appeals 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:

• Ability to maintain a high-volume caseload and adhering 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.
• Receives and reviews 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.
• Demonstrates attention to detail in researching appeal cases and documenting notes for proper case processing.
• 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, health policy, paralegal, or legal assistant studies) and 2 years of relevant work experience.

OR

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

Desirable Qualifications:

• Bachelor's Degree (preferred) or 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 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, multi-task and manage workload to meet specific timeframes and deadlines
• 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.