Complaints, Appeals, and Grievances Coordinator

Minneapolis, Minnesota
Apr 07, 2017
Apr 25, 2017
Employment Status
Full Time

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.




At UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.



Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do.




Position Description

This position is responsible to investigate and coordinate resolution of appeal and grievance cases for Medicaid, Medicare, Medicare Part D, Special Needs and Choices 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, phones, e-mail, and fax queue for urgent or expedited requests.  Specific duties and responsibilities include:


Resolve assigned appeal and grievance cases in a timely manner, consistent with regulatory requirements. Accept new cases received by phone, mail, fax or queue.  Recognize situations that require expedited review or priority handling. Present cases at daily case distribution meeting. Contact members for more details and providers for additional medical information. Communicate case resolution to members and providers in accordance with regulatory expectations. Compile clear, appropriate, and professionally written letters to members regarding resolution. Provide clear and meaningful details of case resolution.

Prepare service appeal case summaries for Medical Director or Pharmacist review and decision.   Consult with Medical Directors, Pharmacists, Compliance, and UCare General Counsel, Delegates and other departments as needed for case resolution.

Plan work processes, monitor timelines, prioritize work, and escalate issues to leadership as appropriate.

Communicate and coordinate with other UCare departments, Delegates 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.

Assist with oversight of the delegated business processes. Participate in Delta Dental and ChiroCare meetings including providing training on regulatory and other changes and facilitating meeting logistics.

Resolve 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.

Assist in the development and annual review of all policies and procedures related to Appeals, Grievances, State Fair Hearings, Quality of Care, and other complex processes ensuring that all regulatory requirements noted.

Identify and communicate opportunities for grievance and appeal process efficiency and improvement.  Participate in the development and updating of reference tools, flowcharts, and training materials.

Assist with reporting needs as requested.

Resolve PCA cases by collecting prior MA Health Status Assessment and clinical notes, present information to Medical Director for review and comment, and notify member of determination.

Prepare Medicare cases for MAXIMUS review.

Represent UCare in State Fair Hearings for Personal Care Assistant (non-legal aid), Pharmacy, Administrative/Benefit, and Claim cases. Prepare case file by collecting information, contacting providers for additional information, compiling and sending case materials to the State Fair Hearing office, the member and others as appropriate, and present case at State Fair Hearings representing UCare in a professional manner.  

Assist with training of new employees and provide training to other departments as directed by the CAG Compliance Specialist, CAG Supervisor or CAG Manager.

Rotate shifts for weekend monitoring of complaint tracking module, phones, e-mail and fax queue for urgent or expedited requests. 

Other duties and projects as assigned.


Bachelor's degree in health related field or equivalent; demonstrated experience may be considered. 

Required Experience

Experience with Medicare and/or Medicaid benefit programs. Demonstrated experience in completing clear and meaningful written and verbal communication. PC skills.

Preferred Experience

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.


UCare is proud to be a recognized Star Tribune Top Workplace for the 7th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply.


As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.


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.

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