MANAGED CARE SPECIALIST 1 - 03032026-75456

Job Information

State of Tennessee Job Information

LOCATION OF (2) POSITION(S) TO BE FILLED: DEPARTMENT OF HEALTH, FAMILY HEALTH AND WELLNESS DIVISION, DAVIDSON COUNTY

This position is designated as Hybrid.

Qualifications

Education and Experience: Graduation from an accredited college or university with an associate's degree.

Substitution of Education for Experience: 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 two 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: One year of full-time work with the State of Tennessee as a Managed Care Technician or a job where the 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

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

Overview

Under immediate supervision, is responsible for professional TennCare program work of routine difficulty; and performs related work as required. An employee in the class performs a variety of TennCare program work including resolving TennCare eligibility appeals, assisting long-term care facilities with claims processing issues, and assisting "walk in" TennCare members or applicants with TennCare claims or eligibility problems. This is the entry-working class in the Managed Care Specialist sub-series. This class differs from that of Managed Care Specialist 2 in that an incumbent of the latter performs TennCare program work of average difficulty with wider scope and complexity.

Responsibilities

An incumbent in this classification learns to perform the following:

• Evaluates the status of provider enrollment to make determination of approval and further participation in Medicaid program.
• Identifies, by appeal timelines, those indicated as standard or emergency appeals to ensure they are processed timely and resolve issues that arise.
• Obtains information from enrollees, medical facilities, providers, and/or managed care organizations in order to identify specific program issues and complete enrollment processes.
• Analyzes data received from contractors to ensure accuracy and functional performance. Learns to evaluate information to identify issues and determine program compliance.
• Documents, stores, and monitors enrollee and/or provider information in electronic database and/or physical form to ensure accurate information.
• Interprets information related to division operations, including Medicaid program specifics, for internal/external business partners to ensure understanding and facilitate relationships.
Networks with internal/external business partners and maintains open dialogue.

Competencies (KSA's)

• Nimble Learning
• Decision Quality
• Manages Conflict
• Action Oriented
• Interpersonal Savvy

Knowledge:

• Customer and Personal Service
• Clerical
• Administration and Management
• Education and Training

Skills:

• Active Learning and Listening
• Critical Thinking
• Reading Comprehension
• Time Management
• Monitoring

Abilities:

• Deductive Reasoning
• Speech Recognition
• Written Comprehension
• Speech Clarity
• Oral Expression

Tools & Equipment

• Personal Computer
• Telephone
• Fax Machine
• Printer