DIRECTOR OF MANAGED CARE PROVIDER RELATIONS - 66082

Executive Service

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.

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:

This position is a part of the Managed Care Operations team, which is a division within TennCare of approximately 35 employees focused on providing oversight of TennCare's managed care entities to ensure contract compliance, program integrity, and operational efficiency. Managed care is Tennessee's health care delivery system arrangement where Tennessee's Medicaid program (TennCare) contracts with health insurance companies known as managed care organizations (MCOs) to deliver health care services to TennCare members. The Managed Care Operations team's role is to work in partnership with TennCare's business areas and TennCare's MCOs to translate Medicaid program requirements into contract language and deliverables and provide oversight and accountability of the MCOs in meeting TennCare's needs.

The Director of Managed Care Provider Relations will be a critical part of the Managed Care Operations team and will report directly to the Deputy Director of the Managed Care Operations division. The Director of Managed Care Provider Relations also oversees a direct report who supports various duties including assistance with strategic planning, reports development and monitoring, and administrative tasks. This role is both a strategic and technical position that must collaborate with internal stakeholders to escalate MCO performance issues, interface with other external stakeholders (e.g., provider groups, Tennessee Department of Commerce and Insurance's [TDCI] TennCare Oversight Division, various medical associations, etc.) to resolve their concerns, and hold TennCare's MCOs accountable.

Key Responsibilities:

• Lead the oversight and monitoring of MCO performance, identifying new and innovative strategies focused on improvement of operational concerns.
• Act as a key point-of-contact for TennCare business units when MCO performance issues endure, providing updated guidance on the various tools (e.g., requests for information, corrective action plans, sanctions, etc.) TennCare has at its disposal to ensure MCO accountability.
• Collaborate with TennCare stakeholders to track and escalate MCO performance issues as part of the agency's monthly Voice-of-the-Customer presentations; work together with these stakeholders to ensure that issues are brought to resolution.
• Monitor MCO operational metrics, inclusive of tracking provider complaints, provider appeals, prompt payment, claims payment accuracy, and claims processing and denials; present information to TennCare leadership teams on strategic recommendations to improve MCO performance, as needed.
• Serve as a primary point of contact with MCO leadership in addressing high-level provider complaints (e.g., claims payments, contracting, and credentialing) and other special projects (e.g., ensuring MCOs are compliant with Federal and CMS regulations, etc.).
• Work closely with multi-disciplinary teams in TennCare, its MCOs, and the Tennessee Department of Commerce & Insurance (TDCI) to review and approve all provider communications issued by the MCOs and processed through TDCI, and ensure appropriate implementation of TennCare requirements (e.g., review MCO provider agreements, etc.).
• Develop and disseminate memoranda concerning TennCare's expectations around compliance with TennCare policy, claims processing, or reimbursement.
• Act as the primary subject matter expert and strategic leader as it pertains to TennCare's coverage of school-based services and its interagency agreement with the Tennessee Department of Education (which covers children enrolled in TennCare and CoverKids receiving health services in a school setting); under this effort, develop and maintain strong partnerships with school stakeholders including Local Education Agencies, TN Department of Education, state and national educational organizations (e.g., Healthy Schools Campaign, National Alliance for Medicaid in Education, etc.), school billing vendors, and managed care staff.
• Act as the program lead and represent managed care concerns in Admission, Discharge, and Transfer (ADT) feeds; Home Health Services Electronic Visit Verification (EVV), MCO telehealth implementation, and other broad systems- and policy-focused initiatives.

Minimum Qualifications:

Bachelor's degree in business or a related field and 5 or more years in a related field with at least 3 years in a supervisory role. Experience may be substituted for education on a year-for-year basis.

Desirable qualifications:

• Strong oral communication and concise and effective written communication skills, with a demonstrated ability for conflict mediation and resolution, customer service, and delivering policy directives or corrective action plans.
• Strong analytical skills, with a demonstrated ability to recognize patterns and trends in data and to find answers to complex questions and problems.
• Demonstrated problem-solving skills with a track record in creating business processes and improving existing ones.
• Strong operational skills, including translating high-level goals to detailed tasks and following them through to completion.
• Strong computer skills including expert proficiency in Microsoft Office applications, especially Word and Excel.
• Demonstrated ability to effectively manage teams of both direct reports and external contractors.
• Strong organizational skills, including the ability to prioritize, multi-task, and manage workload to meet specific timeframes and deadlines.
• A master's degree in business, finance, public administration, public health, public policy, or other related field from an accredited college or university

OR

• A Juris Doctorate: to accompany either degree is at least 3+ years of relevant professional experience in health administration, health insurance, public administration of health services, or other related areas.
• Direct experience working for a state Medicaid agency that uses managed care.

OR

• Direct experience working for a Medicaid managed care organization.
• Experience with health insurance claims and encounter data analysis and processing.
• Experience with healthcare contract procurements (e.g., requests for information, requests for proposals, etc.) and/or contract accountability (e.g., sanctions, corrective action plans, etc.).
• Formal project management background or training

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.