QUALITY & COMPLIANCE DIRECTOR - 74266

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 a Quality and Compliance Director to work in the Compliance and Policy Group (CPG) within Member Services. This position will report directly to the Quality and Compliance Administrator. This position currently has three direct reports and fourteen indirect reports within its reporting line. The Quality and Compliance Director will be responsible for facilitating the Payment Error Rate Measurement (PERM), Medicaid Eligibility Quality Control (MEQC), and Comptroller of the Treasury audits, as well as overseeing Public Assistance Reporting Information System (PARIS) inquiry tasks, Inmate Suspension tasks, eligibility fraud investigations, and federal reporting initiatives. This position requires collaborative work with a variety of internal and external stakeholders to answer questions and resolve concerns related to audits, eligibility processes, PARIS, Inmate Suspension, eligibility fraud investigations, and quality control.

Key Responsibilities:

-Provide high-quality customer service to the Centers for Medicare & Medicaid Services, the Comptroller of the Treasury, and other external audit-related stakeholders.

-Oversee audit work related to the PERM audit, MEQC audit, Comptroller Audit, and annual Risk Assessment, among others.

-Effectuate change across Member Services via case corrections and corrective action plans (CAPs).

-Provide oversight and guidance to three groups of staff: Audit/Quality Control, Compliance, and Eligibility Fraud.

-Maintain a strong understanding of eligibility policies and procedures and apply this knowledge to eligibility audits and quality control tasks.

-Oversee the PARIS inquiry process, ensuring timely and accurate communication with external stakeholders.

-Provide guidance related to the Inmate Suspension process, ensuring timely and accurate resolution of Inmate Suspension tasks.

-Oversee eligibility fraud investigative work, ensuring timely and accurate communication with external stakeholders.

-Ensure and oversee participation the Audit teams' involvement in the Case Reads process to ensure Case Reads outcomes align with federal and state audit expectations.

-Ensure TennCare is compliant with federal reporting requirements.

-Perform vendor compliance tasks, as needed.

Minimum Qualifications:

Education and Experience:

-Graduation from an accredited college or university with a bachelor's degree in a related field and two (2) years of qualifying professional experience;

OR

-Graduation from an accredited college or university with an associate degree in a related field and four (4) years of qualifying professional experience

OR

-eight (8) or more years of qualifying professional experience

OR

-an equivalent combination of education and work experience may be considered

Desirable Qualifications

-Strong customer service skills, including the ability to problem solve, handle difficult situations, and escalate issues when necessary

-Excellent communication skills, both oral and written.

-Advanced research skills, including the ability to locate and analyze documents and integrate information from multiple sources, including researching computer systems

-Excellent organizational skills, including the ability to prioritize, multi-task, and manage workload to meet specific timeframes and deadlines

-Ability to foster and maintain cohesive working relationships

-Ability to interpret and execute policies and procedures

-Ability to exercise sound judgment

-Strong work ethic, with an ability to receive and implement constructive feedback -Ability to work independently while also working as part of a team in a fast-paced environment -Willingness to support and foster the team's culture

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.