LTSS APPEALS SPECIALIST - 72323

Executive Service

LTSS APPEALS SPECIALIST

Division of TennCare

Long Term Services & Support (LTSS)

Nashville, TN

Salary : Minimum Monthly Salary $4,057 / month

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.

Closing Date : 11 / 03 / 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 :

Long-Term Services and Supports (LTSS) is a team within TennCare of highly capable staff who are committed to leading the ongoing development and operation of an innovative, sustainable, person-driven long-term services and supports (LTSS) system in which older adults and people with disabilities and / or chronic conditions have choice, control and access to a full array of high-quality services and supports that assure optimal outcomes, including independence, health and quality of life. Tennessee's CHOICES program includes nursing facility services and home and community-based services (HCBS) for adults 21 years of age and older with a physical disability and seniors (age 65 and older). CHOICES Group 3 is for adults (age 21 and older) with a disability and seniors (age 65 and older) who don't qualify for nursing home care but need a more moderate package of home care services to delay or prevent the need for nursing home care. Employment and Community First (ECF) CHOICES is an integrated Managed Long-Term Services and Supports delivery model. ECF CHOICES is the first program of its kind in the country designed to integrate physical and behavioral health services and Long-Term Services and Supports for individuals with intellectual and developmental disabilities (I / DD) in a person-centered manner that aligns incentives around promoting and supporting employment and integrated community living as the first and preferred option for persons with I / DD. Tennessee's MFP program aligns with the goals of the CHOICES and Employment and Community First CHOICES program and the State's 1915(c) Home and Community-Based Services (HCBS) waivers for individuals with an intellectual disability to help transition eligible individuals from institutions into qualified residences in the community and help rebalance the State's LTSS expenditures. Katie Beckett is the newest program in TennCare Long-Term Services and Supports, specifically for children in Tennessee under the age of 18 with significant disabilities and / or complex medical needs. The Katie Beckett Program provides care for a child's disability or medical needs and allows children to get this care in their homes. The TennCare Program Coordinator (TCPC) will be a critical member within Operations in the LTSS division of Tenncare, under the supervision of the Assistant Director of Operational Compliance

Key Responsibilities :

• Daily receives and reviews appeals for potential resolution within policy guidelines. If resolution cannot be found, move the case forward in the appeal continuum for hearing.
• Ability to maintain a high-volume caseload and adhere to the timeliness standard of appeals while conducting the due process review.
• Demonstrates attention to detail in researching appeal cases and documenting notes for proper case processing.
• Maintaining and tracking operational changes, assist in creating audit and appeals reports that will be used to distribute to upper management as requested.
• Responsible for assisting in reviewing and creating notices to ensure letters are up to date with TennCare rules by applying readability and plain language best practices and ensure adherence to federal and court requirements.
• Ability to understand and clearly communicate complex policy and procedures, establish, and maintain positive working relationships with a wide variety of internal and external stakeholders, manage multiple projects, and adhere to deadlines.
• Ability to adapt to changing priorities, deadlines, and exercise sound judgment.

Minimum Qualifications :

Graduation from an accredited college or university with a bachelor's degree in a related field (preferred : business administration, management, public health, health policy, paralegal, or legal studies) and 2 years of relevant work experience; equivalent combination of education and experience may be considered.

OR

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

Desirable Qualifications :

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.