Eligibility Fraud Investigations Specialist

Opening Date/Time 10/13/2026 12:00AM Central Time

Opening Date/Time 10/13/2026 12:00AM Central Time

Closing Date/Time 10/26/2026 11:59PM Central Time

Salary (Monthly) $3,667.00

Salary (Annually) $44,004.00

Job Type Full-Time

City, State Location Nashville, TN

Department Tenn Care

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.

Graduation from an accredited college or university with a bachelor's degree or graduation from an accredited college or university with an associate's degree and two years of qualifying professional experience related to administrative, customer service and/or data entry positions associated with the application of policy or executing procedural provisions and/or eligibility within a health or healthcare, casework, or an insurance setting.

Qualifying professional experience related to administrative, customer service and/or data entry positions associated with the application of policy or executing procedural provisions and/or eligibility within a health or healthcare, casework, or an insurance setting may substitute for the required education to a maximum of four years (e.g., experience equivalent to one year of full-time work in one or a combination of the above listed fields may substitute for one year of the required education).

Two years of full-time work as a Managed Care Specialist with the State of Tennessee.

A valid motor vehicle operator's license may be required.

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.

Under general supervision, is responsible for highly technical professional Tenn Care program work of considerable difficulty and/or supervisory work of average difficulty; and performs related work as required. This is the highly technical professional or supervisory class in the Managed Care Specialist sub-series. An employee in this class performs highly technical Tenn Care program work or supervises a small to moderate sized unit of Managed Care Specialists and/or sub professional staff performing Tenn Care duties.

This class differs from Managed Care Specialist 2 in that an incumbent of the latter performs Tenn Care program work of average difficulty and is not responsible for highly technical or supervisory work.

• Responsible for investigating cases of suspected Tenn Care eligibility fraud from internal and external stakeholders.
• Work with state entities like Office of Inspector General (OIG), Tennessee Bureau of Investigation (TBI), as well as internal groups to Member Services and Tenn Care Program Integrity to contribute to the financial stability of Tenn Care.
• Assess fraud referral eligibility case information and take appropriate action.
• Responsible for making an outcome determination as to which action to take (no action, making a recommendation for termination, generating an "additional information" notice, or deferring any action because renewal is due) and expedite bringing resolution to cases that need to be closed.
• Responsible for reviewing individual applicant applications and enrollee income, resources and other technical elements.
• Register applications as needed.
• Make changes to member eligibility, establish eligibility.
• Process reports to maintain accurate member caseloads.
• Trouble shoot and respond to inquiries regarding member eligibility.
• Demonstrate strong customer service skills, interpretation of public policy, and problem solving.
• Use proprietary computer-based systems to perform work duties.
• Respond to emails, telephone calls, and other correspondence in a timely fashion.
• Work in a systemic manner in partnership with vendor staff, internal customers, and external stakeholders to provide services and support to a shared client base. This will require verbal and/or electronic communications with the vendor, internal customers and outside organizations and stakeholders to obtain or share information…