QUALITY CONTROL SPECIALIST - 79974

State of Tennessee; Nashville (TN); Hybrid; USD 44,000 - 54,000; Full time

Job summary

TennCare, Tennessee's Medicaid managed care program, seeks a Quality Control Specialist in Nashville. The role focuses on reviewing TEDS casework, ensuring policy compliance, and addressing internal and external inquiries.

The team operates within the Division of TennCare’s Member Services, aiming for high-quality, compliant service delivery. The position offers a hybrid work environment with duties spanning audits, documentation, and collaboration to improve processes and outcomes for

Qualifications

• Bachelor's degree in a related field and 2 years of relevant work experience or an equivalent combination of education and experience.
• Experience in quality control and compliance is preferred.
• Strong writing and communication skills are required.

Responsibilities

• Review and analyze casework in the Tennessee Eligibility Determination System (TEDS).
• Research and analyze processes and documentation to ensure compliance with policy.
• Implement corrective actions based on audit findings.
• Respond to eligibility-related questions from internal and external stakeholders.
• Collaborate to develop procedural documents and guidance related to TEDS casework.

Skills

Quality control

Regulatory compliance

Analytical thinking

Communication skills

Organization

Education

Bachelor's degree

Job description

Executive Service

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.

Executive Service

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.

QUALITY CONTROL SPECIALIST

Division of TennCare

Member Services

Nashville, TN

Minimum Annual Salary $48,684.00

Closing Date: 08/31/2026

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 Medicaid managed care program, serving over 1.4 million Tennesseans, including children, pregnant women, older adults, and individuals with disabilities. With an annual budget exceeding $19.2 billion, TennCare operates under the oversight of 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. At TennCare, we are driven by purpose. Our team is committed to improving outcomes for Tennessee's most vulnerable populations through innovation, integrity, and collaboration. Employees at TennCare report a deep sense of impact and satisfaction in their work. We prioritize people and process equally to create a workplace that values meaningful service, professional development, and shared success.

Job Overview

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.

The Division of TennCare is seeking a Quality Control Specialist in the Compliance and Policy Group within Member Services. This position will report directly to the Assistant Quality Director. This role is responsible for performing quality control tasks within the Tennessee Eligibility Determination System (TEDS), completing federal and State audit tasks, and reviewing casework completed by Member Services employees. Additionally, the Quality Control Specialist will provide accurate and concise responses to quality control inquiries relating to all aspects of Medicaid eligibility and Member Services operations.

Key Responsibilities

• Review and analyze caseworkers' actions taken in TEDS to determine accuracy and compliance with TennCare policy and procedures.
• Research and analyze current and past 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. -Implement corrective action plans resulting from audit/quality control findings.
• Field and respond to all eligibility-related questions from internal and external stakeholders.
• Collaborate with internal and external teams to develop procedural documents and guidance related to TEDS casework.

Minimum Qualifications

Graduation from an accredited college or university with a bachelor's degree in a related field (preferred degree in business administration, management, public health, health policy, paralegal, or legal assistant studies) and 2 years of relevant work experience. OR An equivalent combination of education and work experience may be considered.

Desirable Qualifications

• Experience in quality control such as evaluating the quality of services, identifying problems and needs, and recommending corrective action and improvements to ensure optimum service delivery will be considered a plus
• Research experience, including the ability to locate and analyze documents and integrate information from multiple sources
• Strong grasp of Medicaid policy and experience applying policy knowledge to casework
• Ability to foster and maintain cohesive working relationships
• Ability to adapt to changing priorities and deadlines
• Ability to exercise sound judgment
• Strong organizational skills necessary, including the ability to prioritize, multi-task and manage workload to meet specific timeframes and deadlines
• Advanced writing and communication skills required

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.