ELIGIBILTY FRAUD INVESTIGATIONS MANAGER - 66605

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:

The Division of TennCare is seeking an Eligibility Fraud Investigations Manager for the Eligibility Fraud Unit in the Compliance and Policy Group within Member Services. Under the general supervision of the Quality & Compliance Director, the Eligibility Fraud Investigations Manager will be responsible for serving as the primary liaison to internal and external stakeholders, including the Office of the Inspector General, regarding member and applicant fraud inquiries, while managing a team of up to 12 staff.

The Eligibility Fraud Investigations Manager will be responsible for determining whether applicant or member fraud has occurred and determining relevant actions in the Tennessee Eligibility Determination System (TEDS). This position will also be responsible for quality control measures, collaborating with stakeholders, and proposing solutions to ensure data quality is maintained throughout business units. This position will ensure their staff communicate with all internal and external stakeholders to relay clear, accurate information. Lastly, this position will work collaboratively and proactively with the Compliance and Policy Group to identify areas of concern and create continuous quality and process improvement plans.

Key Responsibilities:

• Supervise a team of up to 12 Managed Care Specialists and other levels of staff
• Liaise with all internal and external stakeholders inquiring about potential applicant or member fraud and quality control
• Review and analyze caseworkers' actions taken in TEDS to determine accuracy and compliance
• Review and analyze 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
• Assist with establishing unit goals, priorities, and strategies as well as ensure communication and action plans are effectively implemented within their area of responsibility
• Collaborate on problem solving and decision-making processes
• Provide regular updates to supervisor about trends and suggest potential solutions
• Design and oversee system improvements and business improvements relating to fraud detection and fraud investigation

Minimum Qualifications:

Education and Experience: Graduation from an accredited college or university with a bachelor's degree and experience equivalent to five years of professional level experience interpreting policy or procedural provisions for a TennCare, Medicaid, managed Care, or other related health insurance organization, of which two years must include drafting contractual requirements, developing rules and regulations, or supervising staff who deal with health insurance.

Substitution of Experience for Education: Five years of full-time work as a Managed Care Specialist, Managed Care Program Mgr, and/or Managed Care Division Director with the State of Tennessee, of which one year must be at the Managed Care Specialist 3 or higher level.

Necessary Special Qualifications: None.

Desirable qualifications:

• Graduation from an accredited college or university with a bachelor's degree and/or experience equivalent to five years of professional level experience interpreting policy or procedural provisions for a TennCare, Medicaid, Managed Care, or other related health insurance organization, or supervising professional staff who deal with health insurance
• Experience with the Software Development Lifecycle (SDLC)
• Experience developing and updating internal business processes

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.