APPEALS LITIGATION SPECIALIST - 72464

Executive Service

APPEALS LITIGATION SPECIALIST

Division of TennCare

Member Services - Appeals Operations Group (AOG)

Nashville, TN

Salary : Minimum Monthly Salary $4,562 / month - 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.

Closing Date : 11 / 10 / 2025

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 :

The Division of TennCare is seeking an Appeals Litigation Specialist for the Appeals Operations Group within Member Services. The Appeals Litigation Specialist will work to resolve appeals prior to hearing by taking appropriate action when applicable and testify on behalf of the Division of TennCare, if the appeal reaches an administrative hearing. The Appeals Litigation Specialist will testify in accordance with established law, rules, regulations, polices and guidelines. The Appeals Litigation Specialist will document actions in TEDS (& other systems) when necessary. Additionally, this role will ensure that due process standards are met in Medicaid appeals by the accurate and timely processing of appeals and all appeals related documents. Finally, the Appeals Litigation Specialist will also work collaboratively with management to identify workflow issues and accomplishments.

Key Responsibilities :

• Ability to maintain a high-volume caseload and adhere to the timeliness standard of appeals while conducting the due process review.
• Assist in the achievement of a high performing and positive work environment that will promote the TennCare Mission.
• Prepares information packets to provide evidence to support the states actions related to TennCare Medicaid programs and offers testimony as the states witness during hearings.
• Daily receives and reviews appeals for potential resolution within policy guidelines. If resolution cannot be found, move the case forward in the appeal continuum for hearing.
• Demonstrates attention to detail in researching appeal cases and documenting notes for proper case processing.
• Attends and actively participates in all unit meetings and problem-solving discussions for workflow improvements.
• Ability to navigate TEDS.

Minimum Qualifications :

Experience and Education : Bachelor's degree and five years of full-time professional experience in one or a combination of the following : social services, human services, auditing, eligibility determination, administrative law, or other legal-related areas. At least two years of this experience must have been in appeals and hearings or a program related position which includes case evaluation, eligibility, and / or policy.

Substitution of Experience for Education : Additional experience in social services, human services, auditing, eligibility determination, administrative law, or other legal-related areas may substitute for the required education on a year-for-year basis.

OR

an equivalent combination of education and work experience may be considered

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.