ASSOCIATE DIRECTOR AND COUNSEL - 80995

TennCare - 3.5 Nashville, TN Job Details Full-time $103,440 - $165,048 a year 5 hours ago Benefits Work from home Qualifications Bar Full Job Description Executive Service

ASSOCIATE DIRECTOR AND COUNSEL

Division of TennCare Chief Medical Office (CMO)

Nashville, TN Minimum Annual Salary:

$103,440.00

Closing Date:

10/19/2026

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 Medicaid managed care program, serving over 1.4 million Tennesseans, including children, pregnant women, older adults, and individuals with disabilities. With an annual budget exceeding $19.2 billion, TennCare operates under the oversight of 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. At TennCare, we are driven by purpose. Our team is committed to improving outcomes for Tennessee's most vulnerable populations through innovation, integrity, and collaboration. Employees at TennCare report a deep sense of impact and satisfaction in their work. We prioritize people and process equally to create a workplace that values meaningful service, professional development, and shared success.

Job Overview:

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. 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 is committed to improving the quality of health care for its members while maximizing the value of every dollar spent. Since its founding, TennCare has been a leader in innovation through clinical care models and delivery system payment reform. TennCare's Medical Office is integral to this mission by leading clinical and quality oversight and strategic innovation for the agency. The medical office is responsible for all medical, dental, behavioral health and pharmacy policy, operations, and appeals as well as quality improvement and population health programming. When a TennCare Managed Care Contractor (MCC) makes an adverse benefit determination affecting one of their assigned TennCare enrollees, the enrollee has the right to appeal the determination to TennCare. If TennCare upholds the MCC's determination, agreeing that the benefit-under-appeal is not medically necessary under TennCare rules, then the enrollee's appeal is set for administrative hearing. 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 the Deputy Director and Counsel of the Appeal Processing Unit, reporting to the TennCare APU Director.

Key Responsibilities:

Supports the APU Director in day-to-day operations to ensure timely, high-quality, and accurate processing of TennCare and CoverKids member benefit appeals- 35%. Evaluate existing appeals processes and identify opportunities to support improved quality of care and cost effectiveness throughout the member benefit appeal process. Identify and review challenging appeal cases and lead collaborative opportunities to learn from challenging cases to improve workflows and processes. Perform legal review of medical appeal cases to formulate courses of action and maintain compliance with applicable state and federal law, especially in support of the T21 processes. Review information submitted by member or member representative to determine if a valid factual dispute is alleged for benefit exclusion denials Conduct reviews of member correspondences including member materials and adverse benefit determination notices to ensure compliance with TennCare Rules and Managed Care Regulations. Assist APU Director in setting and executing the APU vision, goals and priorities and establishing strong collegial work culture for APU team members- 25%. Work closely with agency leadership, APU staff, MCC leadership, other CMO units and other key stakeholders to help inform and guide program direction and improvements Provide direct oversight to the Valid Factual Dispute, Reconsideration and ORR/LD teams in APU. Support onboarding, training, and performance management of team members. Support professional development, build team culture, plan and participate in annual MMA/APU team retreats, and provide on-going feedback to direct reports and all APU team members in support of continued high performance by staff. Support organizational restructuring and training to account for workflow changes, continued MATS implementation and improvements, to maintain high-performing unit. Provide oversight and support to the Medical Appeals Call Center to ensure a high-quality and consistent experience for all members - 20%. Oversee and monitor contract compliance to ensure service level performance standards consistently met by call center vendor. Communicate frequently and establish strong relationships with call center leadership to resolve challenging issues related to call monitoring and the customer experience Perform quality improvement initiatives, provide a and identify opportunities for process changes pertaining to member benefit appeals to enhance the member experience Work closely with the APU Director, APU Deputy Director, and Quality Assurance team on contact call center projects, and trainings. Coordinate and lead regular meetings with APU staff and Managed Care Contractors (MCCs) to discuss appeal trends, outcomes, and resolutions-10%. Coordinate and lead case conferences for APU team to improve processing of member benefit appeals. Partnering with other State agencies and the Managed Care Organizations to assist in coordinating care for their membership. Lead contract oversight related to appeals and failure to provide services to ensure MCC compliance related to member benefit issues and appeals. Other duties as assigned by the APU Director or Medical Director- 10%.

Minimum Qualifications:

Active License to practice law in Tennessee is required.

Preferred Experience:

3+ years of relevant legal experience.

Desirable Qualifications:

Experience with MATS or other database applications, Westlaw, and Interchange Experience with program and project management Prior experience leading and managing teams and direct reports Proficiency in Microsoft Office, including Word, Excel and PowerPoint Self-motived with ability to work well on a team and ability to adapt to changing priorities and deadlines Excellent written, oral, and interpersonal communication skills Strong organizational skills necessary, including the ability to prioritize, multi-task and manage workload to meet specific timeframes and deadlines 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.