ELIGIBILITY FRAUD INVESTIGATIONS SPECIALIST

Job Information

State of Tennessee Job Information

LOCATION OF (1) POSITION(S) TO BE FILLED: DIVISION OF TENNCARE, DAVIDSON COUNTY

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.

Qualifications

Education and Experience: 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.

Substitution of Experience for Education: 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).

Substitution of Experience for Education: Two years of full-time work as a Managed Care Specialist with the State of Tennessee.

Necessary Special Qualifications: A valid motor vehicle operator's license may be required.

Overview

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.

Under general supervision, is responsible for highly technical professional TennCare 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 TennCare program work or supervises a small to moderate sized unit of Managed Care Specialists and/or sub professional staff performing TennCare duties. This class differs from Managed Care Specialist 2 in that an incumbent of the latter performs TennCare program work of average difficulty and is not responsible for highly technical or supervisory work.

Responsibilities

1. Responsible for investigating cases of suspected TennCare eligibility fraud from internal and external stakeholders.

2. Work with state entities like Office of Inspector General (OIG), Tennessee Bureau of Investigation (TBI), as well as internal groups to Member Services and TennCare Program Integrity to contribute to the financial stability of TennCare.

3. Assess fraud referral eligibility case information and take appropriate action.

4. 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.

5. Responsible for reviewing individual applicant applications and enrollee income, resources and other technical elements.

6. Register applications as needed.

7. Make changes to member eligibility, establish eligibility.

8. Process reports to maintain accurate member caseloads.

9. Trouble shoot and respond to inquiries regarding member eligibility.

10. Demonstrate strong customer service skills, interpretation of public policy, and problem solving.

11. Use proprietary computer-based systems to perform work duties.

12. Respond to emails, telephone calls, and other correspondence in a timely fashion.

13. 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 regarding applicant/enrollee circumstances regarding eligibility and to solve eligibility related issues.

14. Be adept at dealing with ambiguity.

15. Manage time and have the ability prioritize tasks.

16. Request guidance and/or training in areas of uncertainty or knowledge deficiency and participate in required training.

17. Strive to improve professional skills and knowledge through continuous learning to better support peers and customers.

18. Exercise professional judgment to know when to escalate a concern or issue.

19. Remain up to date on new policies and procedures as they are implemented to ensure accurate eligibility determination.

20. Ensure accurate and clear communications.

21. Explain eligibility for benefits and services.

22. Interpret policy and procedure in relation to the enrollee's circumstances to ensure the member or applicant's understanding.

23. Communicate the enrollee/applicant's responsibilities to the enrollee/applicant in a way that is easily understood and ensure the enrollee/applicant's understanding.

24. Mentor new and less experienced employees/staff/co-workers to ensure understanding of information/processes, as required.

25. Conducts or leads in training as required to ensure continual learning and current knowledge related to the managed care field.

Competencies (KSA's)

1. Manages Complexity 

2. Organizational Savvy 

3. Directs Work 

4. Communicates Effectively 

5. Instills Trust 

Knowledge:

1. Communication and Media

2. Administration and Management

3. Customer and Personal Service

4. Law and Government

5. Education and Training

Skills:

1. Active Learning and Listening

2. Complex Problem Solving 

3. Judgment and Decision Making 

4. Monitoring

5. Time Management 

Abilities:

1. Written Comprehension

2. Inductive Reasoning 

3. Speech Clarity 

4. Oral Expression

5. Problem Sensitivity 

Tools & Equipment

1. Personal Computer

2. Telephone

3. Fax Machine

4. Printer

Salary : $44,004