This job has now expired
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota’s leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We’re an organization that’s going places. Be part of a team that cares about you, be part of UCare.
Investigate and coordinate activities necessary for the resolutions of appeal and grievance cases for Medicaid, Medicare, Medicare Part D, and Special Needs Plan members. Provide verbal and written communication to members and providers regarding the investigation of appeal and grievance cases. Prioritize and organize work in order to meet regulatory requirements. Rotate shifts for weekend monitoring of the complaint tracking module.
- Resolve assigned appeal and grievance cases in a timely manner, consistent with regulatory requirements.
- Monitor oral grievances taken by Customer Service representatives. Check daily for new cases, review cases for complete documentation, monitor timely and complete resolution of the case, and act as a resource to Customer Service staff regarding grievance process and regulations.
- Communicate and coordinate with other UCare departments and providers as a part of the case investigations. Develop and maintain good working relationships with internal and external customers. Contact providers as appropriate to gain a better understanding of member liability and notification as related to member's appeal or grievance.
- Perform oversight of the delegated business processes. Import and review the Doral monthly report. Oversee the Doral and ChiroCare quarterly meetings including providing training on regulatory and other changes and facilitating meeting logistics.
- Accept and handle calls from the Ombudsman Office. Assist with calls from regulatory agencies such as the Department of Commerce, the Minnesota Department of Health, and the Attorney General's office.
- Participate in review and updated of policies and procedures as assigned by the CAG Manager.
- Collect the Primary Care Clinic quarterly complaint reports, compile the information and disseminate the report.
- Identify and communicate opportunities for grievance and appeal process efficiency and improvement.
- Recommend ongoing development and improvements to the CAG database. Develop, create and report data maintained within the CAG database. As directed by the CAG Manager, create ad hoc reports when necessary for further investigation of appeal and grievance trends.
- Assist in the development and updating of template letters and associated regulatory approval process.
- Participate in the development and updating of reference tools, flowcharts, and training materials.
- Provide training to other departments as directed.
- Rotate shifts for weekend monitoring of the complaint tracking module.
High school graduate or equivalent required. Current LPN preferred. Experience with Medicare and/or Medicaid benefit programs and demonstrated experience in completing clear and meaningful written and verbal communication are required. PC/Computer skills required. Experience answering benefit and claim questions. Claims adjudication process experience. Experience in utilization review. Amisys experience and proficiency in Microsoft Office program - Word, Excel and Access.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve. EOE/AA
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You’ll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis—just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.