LEGAL ASSISTANT - 75727

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.

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:

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 Reimbursement & Billing - RBA team, reporting to the Reimbursement & Billing - RBA Unit Program Manager.

Key Responsibilities:

• The Legal Assistant will be responsible for researching and reviewing incoming TennCare member medical, pharmacy, dental and behavioral health requests and making complex decisions on both issues and appeals under the direction of the TennCare-APU Reimbursement & Billing RBA Unit Manager, the Assistant Director and/or the 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 other team Legal Assistants, the team Leads, and APU management to review member appeals and ensure appeals are processed in an accurate and timely manner.
• The Legal Assistant duties will include researching the issue/appeals within the MATS tracking database, to determine if issue/appeal information has been added; updating MATS as needed, drafting and editing documents related to each issue/appeal case, sending and receiving issue/appeal information to and from the managed care organizations, organizing and maintaining documentation on case files processed by the Reimbursement & Billing RBA Unit for easy retrieval.
• The Legal Assistant will also write summations on issue/appeal cases and will edit summaries as needed, identifying and summarizing critical issue/appeal information for management review.
• The Legal Assistant will perform other duties as assigned by the APU Reimbursement & Billing RBA Manager, the Assistant Director and/or the Managed Care Director for cross-training and based on business needs.

Minimum Qualifications:

Education and Experience:

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

(1) an associate's degree in paralegal or legal assistant studies.

(2) a bachelor's degree in paralegal or legal assistant studies.

(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 researching legal issues and documenting findings to assist in building case files, settling legal disputes, and/or providing legal counsel to clients. Desirable Qualifications -Experience with MATS or other database applications -Experience in the healthcare field

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.