LEGAL ASSISTANT - 64433

Executive Service

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 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:

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 Appeal Valid Factual Dispute team, reporting to the Valid Factual Dispute Unit Program Manager.

Key Responsibilities:

• The Legal Assistant will be responsible for researching and reviewing incoming TennCare medical, pharmacy, dental and behavioral health appeals and making complex decisions on both issues and appeals under the direction of the TennCare Managed Care Director. Determinations must be made timely and within a court-ordered deadline of 90 days for a standard appeal. Appeals of an adverse action that are reviewed are subject to a valid factual dispute determination unless untimely or enrollee is ineligible on the date of service. The Legal Assistant will also work with management to review member appeals and ensure appeals are processed in an accurate and timely manner - 40%
• The Legal Assistant duties will include researching the appeals tracking database, MATS, to determine if appeal information has been added; updating MATS as needed, drafting and editing documents related to each appeal case, sending and receiving appeal information to and from the managed care organizations, and organizing and maintaining documentation on case files processed by the Valid Factual Dispute Unit for easy retrieval - 30%
• The Legal Assistant will also write summations on appeal cases and edits summaries as needed, identifying and summarizing critical appeal issues for management review - 20%
• The Legal Assistant will perform other duties as assigned by the VFD Program Manager or APU Director - 10%

Minimum Qualifications:

Education equivalent to graduation from an accredited college, university, or professional school with one of the following:

• (1) an associate degree in paralegal or legal assistant studies, public health, healthy policy, or social services; (2) a bachelor's degree in paralegal or legal assistant studies, public health, health policy, or social services; (3) a paralegal certificate; or (4) one year (28 semester hours) of graduate level law school.

OR

• Education equivalent to graduation from a standard high school and two years of full-time experience in (1) positions associated with the application of policy or executing procedural provisions and/or eligibility within a health, healthcare, or health insurance setting; or (2) researching legal issues and documenting findings to assist in building case files.

OR

• An equivalent combination of education and work experience may be considered.
• Ability to maintain excellent professional and inter-personal relationships and the ability to multi-task when priorities are changed and be amenable to assuming a wide variety of special assignments as directed.
• Ability to prioritize conflicting needs, handle matters expeditiously and proactively, and follow-through on projects to successful completion within established deadlines.
• Must be detail oriented and have demonstrable organization, facilitation, and communication skills.
• Must have strong written communication, writing letters, emails, and reports on behalf of the office staff.

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.