MANAGED CARE SPECIALIST 3 - 10222024-62536
Company: State of Tennessee
Location: Nashville
Posted on: October 23, 2024
Job Description:
Job Information State of Tennessee Job InformationOpening
Date/Time10/22/2024 12:00AM Central TimeClosing Date/Time11/04/2024
11:59PM Central TimeSalary (Monthly)$3,595.00 - $5,380.00Salary
(Annually)$43,140.00 - $64,560.00Job TypeFull-TimeCity, State
LocationNashville, TNDepartmentTennCare LOCATION OF (1) POSITION(S)
TO BE FILLED: DIVISION OF TENNCARE, ELIGIBILITY DETERMINATION
STAFF, DAVIDSON COUNTYJob Title: Rapid Response 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.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. 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.
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. Examination Method: Education
and Experience,100%,for Preferred Service positions. Overview
Summary: 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. Distinguishing Features: 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 Monitoring and Controlling Resources:
- Identifies inconsistencies and errors in policies, rules,
procedures and suggest corrective action to management.
- Follows policies, rules, procedures to ensure that taxpayers
receive value from tax dollars.
- Ensures resources are available to allow staff to complete job
duties in a timely and efficient manner.Establishing and
Maintaining Interpersonal Relationships:
- Networks with external and internal business partners to ensure
open dialogue exists and to facilitate coordination and unified
effort.
- Maintains professional working relationships with peers and
with upper management to ensure smooth and effective team
operations.
- Leads peers/subordinates to liaise with other state agencies,
and outside entities to ensure accurate and timely processing of
enrollee/provider requests.Processing Information:
- Leads peers/subordinates in compiling information received via
mail/fax/call center into an electronic database to begin initial
process for program participation related to application, appeals,
recertification's, etc.
- Leads peers/subordinates in preparing provider rates for
nursing homes and out of state hospitals to be loaded into
electronic database to determine the appropriate per diem rate paid
for services rendered.
- Processes returned information to verify specific enrollment or
denial criteria for participation in the HCFA/TennCare
program.
- Processes information sent to and received from contractors to
determine the next step in the appeals process and assigns the
process to a peer/subordinate.
- Verifies provider information received to initiate a survey
from Department of Health, Healthcare Facilities, for the purpose
of opening a new Intermediate Care Facility for the developmentally
challenged.
- Calculates information received from contractors and compiles
data for monthly and quarterly federal reporting.
- Verifies the accuracy and completeness of information received,
and ensures that it is processed within required time
frames.Communicating with Supervisors, Peers, or Subordinates:
- Provides regular updates to upper management and other internal
business partners on the status of assigned work or an assigned
project to facilitate understanding and resolution.
- Conducts a variety of meetings to provide and gather status
updates for assigned workload.
- Provides updates to assigned supervisor to ensure accurate and
timely receipt of instructions and work assignments.Communicating
with Persons Outside Organization:
- Communicates with external business partners with appropriate
written or oral notifications related to specific program
information to ensure understanding, facilitate services and
expedite claims or appeals.
- Contacts vendors and other outside agencies related to
HCFA/TennCare to obtain/provide required information and/or for
clarification purposes.
- Answers or responds to complex inquiries from external business
partners for the purpose of relaying and/or correcting information,
and policy/guideline interpretation.Staffing Organizational
Units:
- Anticipates staffing needs and requests hiring requisition
within stated guidelines to ensure appropriate staffing levels for
work at hand.
- Interviews selected applicants using applicable state and
federal guidelines to choose the most suited candidate for the open
position.
- Uses best business practices to appoint and promote most
qualified employee for assigned position.Provide Consultation and
Advice to Others:
- Provides consultation and advice relating to federal and state
health policies to internal and external partners, applicants and
other interested stakeholders.
- Trains/educates internal and external partners and other
interested stakeholders related to agency programs and
services.Guiding, Directing, and Motivating Subordinates:
- Completes the performance management process for each direct
report to include a job planning discussion, two interims and a
formal evaluation, all based on the SMART formula.
- Provides ongoing feedback related to assigned tasks to ensure
complete understanding, accuracy of work and appropriate deadlines
are met.Making Decisions and Solving Problems:
- Leads the analysis of data received from contractors to ensure
accuracy and functional performance prior to live
implementation.
- Analyzes errors identified through electronic process and
assigns to peers/subordinates to resolve issues in order to
complete enrollment in the HCFA/TennCare program.Updating and Using
Relevant Knowledge:
- Conducts or leads in training as required to ensure continual
learning and current knowledge related to the managed care field in
order to access applicable systems.
- Utilizes acquired knowledge and skills to improve daily
performance of assigned tasks.Identifying Objects, Actions, and
Events:
- Leads the identifying of those appeals indicated as emergency
appeals to ensure they are processed timely and within the required
time frame.
- Leads the identifying of those appeals indicated as standard
appeals to ensure they are processed within the required time
frame.Judging the Qualities of Things, Services, or People:
- Leads in assessing the information received through the Help
Desk/Call Center to evaluate and/or prioritize for issue
resolution.Analyzing Data or Information:
- Leads the analysis of data received from contractors to ensure
accuracy and functional performance prior to live
implementation.Interacting With Computers:
- Uses appropriate data base tracking software, specific to the
State and Agency, as required, to perform assigned tasks.
- Uses office productivity software, including but not limited
to, word processing programs, spreadsheets programs, presentation
software, web-based email programs and search engines to perform
assigned tasks.
- Utilizes state and federal databases as required in order to
verify current data and/or obtain updates.Documenting/Recording
Information:
- Leads peers/subordinates in documenting and storing enrollee
and/or provider information in electronic databases and/or physical
form, to track appeals as required for administrative
processes.
- Leads peers/subordinates in recording and monitoring enrollee
and/or provider calls and stores electronic information for the
applicable time frame to ensure accurate information is provided,
concerns addressed, and final resolution is achieved.
- Leads documentation and management of enrollee changes to
Managed Care Organization rosters to ensure accurate information is
reflected for benefits.Interpreting the Meaning of Information for
Others:
- Interprets specialized information related to division
operations for internal and external business partners to ensure
understanding and facilitate relationships.
- Explains HCFA/TennCare program specific procedures, guidelines
and regulations to the general public, persons in other departments
or divisions, or outside organizations or representatives as
required, in response to basic inquiries.Organizing, Planning, and
Prioritizing Work:
- Organizes and prioritizes personal and/or unit workloads to
ensure timely and accurate completion of daily workflow.
- Incorporates last minute and unscheduled tasks into current
workload to ensure timely and accurate completion of daily
work.Developing and Building Teams:
- Facilitates, develops and maintains working relationships with
team members to enhance productivity and effectively serve customer
needs and promote self sufficiency within the work unit.
- Assigns smaller work groups, built on the strength of
individuals within teams, to enhance relationships and facilitate
workload products.Resolving Conflicts and Negotiating with
Others:
- Resolves intermediate conflicts without supervisory input to
ensure timely and efficient performance and maintain positive
working relationships.
- Directs complex conflicts to assigned supervisor or Human
Resources, as required.Coordinating the Work and Activities of
Others:
- Coordinates workload of peers/subordinates with internal and
external business partners as required to facilitate timely and
accurate task completion.
- Coordinating with upper management, peers, and assigned
subordinates to facilitate equitable workload distribution.
- Coordinates meetings, events and other special projects to
ensure attendance, availability and coverage of work area.
- Prioritizes employees' daily/weekly/monthly work to ensure all
work is completed by established deadlines and meets quality
standards.Evaluating Information to Determine Compliance with
Standards:
- Leads peers/subordinates to evaluate the status of provider
enrollment based on disclosure information provided in application
in order to make a determination of approval and further
participation in Medicaid program.
- Leads in evaluating the information received from the
Department of Health, Health Care Facilities' surveys for
compliance and/or renewal of Nursing Facility contracts.Performing
Administrative Activities:
- Enters personal time and leave/overtime requests into the
appropriate database as required to ensure accurate time and labor
processing.
- Approves staff time and leave/overtime requests in the
appropriate database as required to ensure accurate time and labor
processing.
- Responds to emails, telephone calls, and other correspondence
in a timely fashion.
- Scans, uploads, faxes and/or email backup copies of appeals,
provider and enrollee correspondence, or other information to
ensure proper documentation and preservation.
- Performs a variety of professional administrative duties
related to: eligibility determinations, missed appeals and/or
status of appeals, contract compliance, tracking correspondence to
resolution, provider applications, etc.Getting Information:
- Leads the obtaining of information via emails from call center
or faxes/mail from outside entities in order to identify issues
from enrollees, medical facilities, providers, and/or Managed Care
Organizations.
- Observes the identification of whether providers want to be
linked to a specific group, or enrolled as an individual
entity.
- Leads the contacting of providers, enrollees or other outside
entities via telephone or email for additional information in order
to complete the enrollment process and/or resolve issues.
- Conducts meetings to obtain necessary information needed to
achieve operational objectives.
- Oversees the gathering of information from written Standard
Operating Procedures to ensure all processes are followed.Monitor
Processes, Materials, or Surroundings:
- Leads the monitoring of the provider paper and/or electronic
enrollment files to identify missing/incorrect information in
database relevant to ensuring timely processing of payment to
providers.
- Leads the monitoring of provider paper and/or electronic files
to identify sanctions or terminations to prevent ineligible
participation in the TennCare program.
- Leads the reviewing of mail batch processing to track provider
applications and identify pending status of approval for
participation in TennCare program.
- Monitors the work of peers/subordinates to ensure appeals are
processed timely and within court mandated timeframes for
compliance.
- Reviews the work of peers/assigned subordinates in monitoring
file tracking queue to ensure pending issues have been identified
and distributed to Legal Assistants and/or other appropriate staff
for processing.
- Leads the review of system information to determine if
additional information will be needed to complete the eligibility
process and request said information.
- Reviews queue of pending pre-admission evaluations to determine
if program criteria have been met for determination of financial
eligibility.Coaching and Developing Others:
- Mentors new and less experienced employees/staff/co-worker to
ensure understanding of information/processes, as required.
- Identifies training opportunities for staff and facilitates
attendance.
- Provides one-on-one interaction and discussion to determine
additional resources to develop and/or improve job
skills.Competencies (KSA's) Competencies:
- Dealing with Ambiguity
- Problem Solving
- Delegation
- Time Management
- Command Skills
- Standing Alone
- Perseverance
- Organizational Agility
- Written Communication
- Approachability
- Customer Focus
- Integrity and TrustKnowledge:
- Communication and Media
- Administration and Management
- Customer and Personal Service
- Law and Government
- Education and TrainingSkills:
- Speaking
- Writing
- Monitoring
- Active Listening
- Critical Thinking
- Instructing
- Negotiation
- Reading Comprehension
- Time Management
- Complex Problem Solving
- Trouble Shooting
- Judgment and Decision Making
- Systems EvaluationsAbilities:
- Category Flexibility
- Inductive Reasoning
- Oral Comprehension
- Oral Expression
- Problem Sensitivity
- Written Comprehension
- Written Expression
- Time Sharing
- Speech Clarity
- Speech RecognitionTools & Equipment
- Personal Computer
- Telephone
- Fax Machine
- Printer
Keywords: State of Tennessee, Nashville , MANAGED CARE SPECIALIST 3 - 10222024-62536, Other , Nashville, Tennessee
Didn't find what you're looking for? Search again!
Loading more jobs...