PUBLIC HEALTH NURSE CONSULTANT - 04142026- 76636

Job Information

LOCATION OF (1) POSITION(S) TO BE FILLED: DIVISION OF TENNCARE, TENNCARE DIVISION, DAVIDSON COUNTY

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.

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.

Qualifications

Education and Experience: Graduation from an accredited college or university with a bachelor's degree in nursing and experience equivalent to four years of full-time increasingly responsible professional nursing work.

Substitution of Experience for Education: Qualifying full-time experience in nursing may be substituted for the required education on a year-for-year basis, to a maximum of two years.

Substitution of Graduate Education for Experience: Additional graduate coursework in nursing may be substituted for the required experience on a year-for-year basis to a maximum of one year.

Necessary Special Qualifications: Licensed as a Registered Nurse in the State of Tennessee.

Overview

Operationally, the TennCare Appeal Processing Unit works closely with several other TennCare divisions to help process TennCare member appeals for all eligible TennCare members to ensure they receive their medically necessary care.

Externally, the Appeal Processing Unit (APU) works with TennCare's managed care organizations and other state agencies to ensure the provision of covered medical, dental, behavioral health, and pharmacy services for TennCare Members. This position will be a key member on the APU Nurse Reviewers Team reporting to the Nurse Reviewer Program Manager

Responsibilities

The Public Health Nurse Consultant (PHNC) will be responsible for utilizing the Member Appeal Tracking System (MATS) to process medical appeals accurately and in a timely manner, ensuring quality appeal processing.

Responsibilities include processing medical appeals, generating notices and tasks, redacting and reindexing files, managing Protected Health Information (PHI), and tracking file progress using task statistics and reporting tools. The PHNC will perform quality assurance reviews of medical files, ensuring compliance with TennCare rules, accurate member information, and timely resolution of appeals. They will also participate in case conferences and team meetings to identify workflow improvements and opportunities to enhance the member appeal experience.

The PHNC will engage in ongoing professional development through training programs, interagency collaboration, and self-initiated learning to enhance skills and processes. They will monitor updates to TennCare rules and policies, implement changes, and develop training resources to improve understanding and application of medical rules.

The PHNC will analyze appeal data to identify trends and issues, make appropriate referrals, and collaborate with cross-functional teams to improve the quality of the medical appeal process. Additionally, they will provide feedback and referrals for Managed Care Contractor meetings, addressing complaints, quality concerns, and missed shifts to ensure an optimal experience for members and providers.

Competencies (KSA's)

1. Instills Trust
2. Decision Quality
3. Manages Conflict
4. Interpersonal Savvy
5. Plans and Aligns

1. Administration and Management
2. Nursing Practices & Procedures
3. Law and Government
4. Customer and Personal Service
5. Psychology

1. Social Perceptiveness
2. Active Learning and Listening
3. Writing
4. Reading Comprehension
5. Quality Control Analysis

1. Information Ordering
2. Problem Sensitivity
3. Limb and/or Full Body Coordination
4. Deductive Reasoning
5. Speech Clarity

Tools & Equipment

1. Personal Computer
2. Telephone
3. Calculator
4. Printer