ASSOCIATE COUNSEL - 7498

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:

TennCare operates under a managed care model, partnering with 5 managed care contractors, called MCCs. The 5 MCCs consist of 3 managed care organizations (MCOs), a dental benefit manager (DBM), and a pharmacy benefit manager (PBM). Operating our program under a managed care model allows us to align payment incentives with performance goals and better equips our agency with the tools we need to contain cost while promoting high quality care for our enrollees. When a TennCare MCC makes an adverse benefit determination affecting one of their assigned TennCare enrollees, the enrollee has the right to appeal the determination to TennCare. Two units together process all medical, dental, and pharmacy appeals, the Appeals Processing Unit (APU) and Office of Fair Hearing (OFH). The Appeals Processing Unit hosts the appeal call center and completes the intake and processing of a medical member appeal. If TennCare upholds the MCC's determination, agreeing that the benefit-under-appeal is not medically necessary under TennCare rules, then OFH is responsible for setting the enrollee's appeal for administrative hearing, and for representing TennCare at the hearing. The OFH is close-knit, collegial team comprised of about 10 attorneys and 20 legal support staff. Most hearings are conducted remotely, with the judge, the witnesses, and the parties (the TennCare pro se enrollee/enrollee's representative and the assigned OFH attorney) each appearing separately by telephone or virtually.

Key Responsibilities:

1. Appeals Representation:

• Represent the Division in appeals regarding denied medical services.
• Engage with TennCare enrollees, legal services attorneys, private counsel, and other stakeholders involved in appeals.

2. Case Management:

• Direct Legal Assistants in gathering necessary case information, including documents generated by the Division, Managed Care Contractors, enrollees, health providers, witnesses, and hearing exhibits.
• Ensure completeness and accuracy of all case-related documentation.

3. Database Management:

• Update and maintain the appeals tracking database to reflect the current status and details of cases.
• Provide regular updates and reports to ensure compliance and efficiency.

4. Hearing Preparation:

• Oversee the preparation of hearing exhibits, including collection, organization, and submission.
• Inform witnesses of hearing procedures and coordinate their participation.
• Review all drafts of case pleadings, including affidavits, motions, subpoenas, and other legal documents, to ensure accuracy and adherence to legal standards.

5. Team Collaboration:

• Provide clear direction and guidance to Legal Assistants on case preparation and procedural requirements.
• Collaborate with other team members to address complex legal issues and develop strategies for case resolution.

Minimum Qualifications:

• Active License to practice law in Tennessee is required. Preferred Experience: 3+ years of relevant legal experience.
• Desirable Qualifications
• Strong understanding of administrative law, healthcare law, and appeals processes.
• Excellent organizational and case management skills.
• Exceptional written and verbal communication abilities.
• Ability to work collaboratively with a legal team and manage multiple priorities in a fast-paced environment.

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.