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
  

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