MANAGED CARE SPECIALIST 1 - 03032026-75456

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:

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

Competencies (KSA's)

1. Nimble Learning
2. Decision Quality
3. Manages Conflict
4. Action Oriented
5. Interpersonal Savvy

Knowledge:

1. Customer and Personal Service
2. Clerical
3. Administration and Management
4. Education and Training

Skills:

1. Active Learning and Listening
2. Critical Thinking
3. Reading Comprehension
4. Time Management
5. Monitoring

Abilities:

1. Deductive Reasoning
2. Speech Recognition
3. Written Comprehension
4. Speech Clarity
5. Oral Expression

Tools & Equipment

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