MANAGED CARE SPECIALIST 3 - 10282025-72336

Job Information

LOCATION OF (1) POSITION(S) TO BE FILLED: DIVISION OF TENNCARE, TENNCARE DIVISION, DAVIDSON COUNTY

Working Title: Quality Assurance Specialist

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 criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.

Qualifications

Education and Experience: Graduation from an accredited college or university with a bachelor's degree or graduation from an accredited college or university with an associate's degree and two years of qualifying professional experience related to administrative, customer service and/or data entry positions associated with the application of policy or executing procedural provisions and/or eligibility within a health or healthcare, casework, or an insurance setting.

Substitution of Experience for Education: Qualifying professional experience related to administrative, customer service and/or data entry positions associated with the application of policy or executing procedural provisions and/or eligibility within a health or healthcare, casework, or an insurance setting may substitute for the required education to a maximum of four years (e.g., experience equivalent to one year of full-time work in one or a combination of the above listed fields may substitute for one year of the required education).

Substitution of Experience for Education: Two years of full-time work as a Managed Care Specialist with the State of Tennessee.

Necessary Special Qualifications: A valid motor vehicle operator's license may be required.

Overview

Under general supervision, is responsible for highly technical professional TennCare program work of considerable difficulty and/or supervisory work of average difficulty; and performs related work as required. This is the highly technical professional or supervisory class in the Managed Care Specialist sub-series. An employee in this class performs highly technical TennCare program work or supervises a small to moderate sized unit of Managed Care Specialists and/or sub professional staff performing TennCare duties. This class differs from Managed Care Specialist 2 in that an incumbent of the latter performs TennCare program work of average difficulty and is not responsible for highly technical or supervisory work.

Responsibilities

1. Leads peers/subordinates in compiling information for initial processes for program participation related to application, appeals, recertifications, etc. Leads in preparation of provider rates, the analysis of data from contractors, processes specific enrollment information, and verifies accuracy of information.
2. Leads peers/subordinates in documentation and storing enrollee and/or provider information in electronic databases and/or physical form to track appeals, monitoring information, and ensuring accurate information.
3. Completes the performance management process for direct reports and provides feedback related to assigned tasks. Conducts/leads training as required. Coordinates workload of peers/subordinates with internal/external business partners as required to facilitate task completion.
4. Follows policies and procedures and identifies inconsistencies and errors to suggest corrective action to management.
5. Provides regular updates to upper management and other partners on the status of assigned work or assigned projects.
6. Provides consultation and advice relating to federal and state health policies to internal/external partners, applicants, and other stakeholders.
7. Networks with internal/external business partners and maintains open dialogue. Leads peer/subordinates to liaise with other entities to ensure processing of requests.

Competencies (KSA's)

1. Manages Complexity
2. Organizational Savvy
3. Directs Work
4. Communicates Effectively
5. Instills Trust

Knowledge:

1. Communication and Media
2. Administration and Management
3. Customer and Personal Service
4. Law and Government
5. Education and Training

Skills:

1. Active Learning and Listening
2. Complex Problem Solving
3. Judgment and Decision Making
4. Monitoring
5. Time Management

Abilities:

1. Written Comprehension
2. Inductive Reasoning
3. Speech Clarity
4. Oral Expression
5. Problem Sensitivity

Tools & Equipment

1. Personal Computer
2. Telephone
3. Fax Machine
4. Printer