Quality Control Specialist - 79974

Executive Service

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.

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.

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.

Tenn Care 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, Tenn Care operates under the oversight of the Centers for Medicare and Medicaid Services (CMS).

Tenn Care's mission is to improve the lives of Tennesseans by providing high-quality, cost-effective care. At Tenn Care, 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 Tenn Care 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.

Tenn Care 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 Tenn Care is dedicated to providing our employees with a hybrid work environment. All Tenn Care 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.

The Division of Tenn Care is seeking a Quality Control Specialist in the Compliance and Policy Group within Member Services. This position will report directly to the Assistant Quality Director. This role is responsible for performing quality control tasks within the Tennessee Eligibility Determination System (TEDS), completing federal and State audit tasks, and reviewing casework completed by Member Services employees. Additionally, the Quality Control Specialist will provide accurate and concise responses to quality control inquiries relating to all aspects of Medicaid eligibility and Member Services operations.

• Review and analyze caseworkers' actions taken in TEDS to determine accuracy and compliance with Tenn Care policy and procedures.
• Research and analyze current and past business processes, system functionality, and eligibility documentation to ensure compliance with regulatory authority and internal requirements.
• Remain current on all Medicaid eligibility policy updates and TEDS design materials.
  
  -Implement corrective action plans resulting from audit/quality control findings.
• Field and respond to all eligibility-related questions from internal and external stakeholders.
• Collaborate with internal and external teams to develop procedural documents and guidance related to TEDS casework.

Graduation from an accredited college or university with a bachelor's degree in a related field (preferred degree in business administration, management, public health, health policy, paralegal, or legal assistant studies) and 2 years of relevant work experience. OR An equivalent combination of education and work experience may be considered.

• Experience in quality control such as evaluating the quality of services, identifying problems and needs, and recommending corrective action and improvements to ensure optimum service delivery will be considered a plus
• Research experience, including the ability to locate and analyze documents and integrate information from multiple sources
• Strong grasp of Medicaid policy and experience applying policy knowledge to casework
• Ability to foster and maintain cohesive working relationships
• Ability to adapt to changing priorities and deadlines
• Ability to exercise sound judgment
• Strong organizational skills necessary, including the ability to prioritize, multi-task and manage workload to meet specific time frames and deadlines
• Advanced writing and communication skills required

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…