Closing Date: 31st March, 2025
Description:
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:
The Division of TennCare's Office of Fair Hearings (OFH) seeks a new attorney to join our team. Operating out of the TennCare Chief Medical Office's Member Medical Appeals Department, OFH attorneys are responsible for representing the Division of TennCare at administrative appeal hearings requested by TennCare enrollees. With the assistance of OFH support staff, and colleagues, the OFH Associate Counsel bears responsibility for marshalling, organizing and timely issuing the exhibits and legal pleadings forming the basis for the adverse benefit determination and for preparing the medical expert witness for testifying at the scheduled hearing. The Associate Counsel will also provide direction related to hearing preparation related to hearing exhibits collection and preparation; informing witnesses of hearing procedures; and, reviewing all drafts of case pleadings including affidavits, sworn declarations, motions, and other documents. The OFH Associate Counsel bears responsibility for representing TennCare at the scheduled in-person or virtual hearing. The OFH Associate Counsel position will be responsible for working remotely except for occasional required in-office days.
Minimum Qualifications:
Education:
Candidate must have a Juris Doctor degree from an accredited law school in the United States.
Licensed in Good Standing:
Candidate must have an active Tennessee license to practice law and must be in good standing.
Desirable Qualifications:
Candidate must have an active Tennessee license to practice law and must be in good standing.
Desirable Qualifications:
- Coursework and/or demonstrated understanding of administrative law and the Tennessee uniform administrative procedures act.
- Demonstrated understanding of managed care, federal Medicaid regulations, the TennCare program or TennCare's member medical appeal process.
- Exceptional written and oral advocacy skills, as evidenced by legal experience or participation in law review, law journal, or moot court during law school.
- Ability to work collaboratively with a legal team and manage multiple priorities in a fast-paced environment.
- Desire to develop oral advocacy and administrative litigation skills and to develop expertise in Medicaid managed care law.
