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Job Description
DIRECTOR OF OFFICE OF FAIR HEARINGS AND POST-HEARING APPEALS AND DIRECTIVES - 78382
TennCare - 3.5 Nashville, TN Job Details Full-time From $118,296 a year 23 hours ago Benefits Work from home Qualifications Policy analysis Full Job Description Executive Service
DIRECTOR OF OFFICE OF FAIR HEARINGS AND POST-HEARING APPEALS AND DIRECTIVES
Division of TennCare Chief Medical Office (CMO) Nashville, TN Minimum Salary $118,296/
Year Closing Date:
07/06/2026 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.
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:
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. The Office of Fair Hearings (OFH) & Post Hearing Appeals and Directives (Post) is comprised of attorneys and legal support staff. The Director of OFH/Post is responsible for leading this team of 25 individuals and is a key member of the CMO senior leadership team. OFH & Post work closely alongside the Appeals Processing Unit and together make up the Member Medical Appeals department. 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. Most hearings are conducted remotely, with the administrative law judge, the witnesses, and the parties each appearing separately, usually by telephone and occasionally by video conference. The Director of OFH/Post leads the oversight of the full member hearing process while helping to support a strong member experience and collaborative team approach.
Key Responsibilities:
Lead ongoing operational compliance and serve as TennCare's subject matter expert for fair hearing and post-hearing appeals requirements Interpret and apply TennCare rules, federal CMS regulations, the Tennessee Uniform Administrative Procedures Act, applicable civil procedure and evidentiary standards, and related contractual requirements Lead the development and revision of TennCare policies, rules, and operational procedures governing medical appeals and hearings Ensure all hearing and post-hearing logistics and operational procedures are consistent and timely. Lead quality improvement initiatives to support member and team experience. Provide strategic legal guidance and risk assessment to executive leadership regarding complex appeals, regulatory developments, litigation-related matters, and high-profile or precedent-setting cases Oversee compliance with Managed Care Contractor contractual obligations, Independent Medical Review requirements, and other applicable regulatory and accreditation standards Partner with TennCare leadership and external stakeholders to address operational, legal, and policy issues related to appeals and hearings Advise OFH/Post legal team and provide recommendations related to appeals operations, legal risk, policy implications, and program performance Build and maintain collaborative relationships with key internal and external stakeholders including TennCare and CMO senior leadership, Managed Care Contractors, the Administrative Procedures Division, CMS, and other governmental partners Represent TennCare in executive-level meetings, interagency collaborations, audits, regulatory reviews, and other forums involving appeals and hearing operations Prepare and present executive-level briefings, recommendations, reports, and strategic analyses that support informed decision-making and organizational accountability. Lead workforce development and organizational change efforts that strengthen the effectiveness of OFH and Post-Hearing Appeals operations Provide coaching, mentorship, performance management, and leadership support for legal assistants, attorneys, managers, and operational leaders Support workforce planning, recruitment, onboarding, employee engagement, leadership development, corrective action, and retention strategies Lead organizational change initiatives through stakeholder engagement, communication planning, training, and performance monitoring while promoting a collaborative workplace focused on accountability, continuous learning, innovation, and operational excellence
Minimum Qualifications:
A current, valid license to practice law in Tennessee or be eligible for licensure under Tennessee Supreme Court Rule 7, Article X. 5+ years of relevant legal experience OR an equivalent combination of education and work experience may be considered. 3+ years of supervisory experience. Desirable Qualifications Coursework and/or demonstrated understanding of administrative law and the Tennessee Uniform Administrative Procedures Act. Demonstrated understanding of managed care, federal Medicaid regulations, the TennCare program or TennCare's member medical appeal process. Exceptional written and oral advocacy skills, as evidenced by legal experience or participation in law review, law journal, or moot court during law school. Ability to work collaboratively with a legal team and manage multiple priorities in a fast-paced environment. Experience with administrative litigation skills and/or expertise in Medicaid managed care law. 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.
