Quality & Regulatory Specialist

Minneapolis, Minnesota
Oct 13, 2017
Nov 21, 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, resolve and respond to Quality of Care complaints.  Support Clinical Services and Behavioral Health with government regulatory audits and coordinate the preparation for accreditation surveys.  Collaborate across departments, with consultants, and develop strong relationships with all stakeholders.  Responsibilities may also include serving as the NCQA business owner designee as assigned by the Chief Nursing Officer (CNO) or other serving as the designee at other internal committees and/or work groups as assigned by the CNO. This position requires interpretation and application of state and federal regulatory mandates, regulations and rules, and a strong understanding of NCQA standards.  Specific duties and responsibilities include:


Facilitate the Quality of Care (QOC) process from receipt of complaint through the final steps of member and provider correspondence.

Assist, research, and/or prepare QOC case investigation and ensure resolution in a timely manner.

Ensure entry of data requirements and necessary tracking of QOC in to designated database(s).

Maintain QOC tracker documentation to ensure case files are complete and accurately reflect the investigation and disposition of the case.

Evaluate and research each case, gather appropriate information, identify best practices, and provide clinical recommendation for medical director review.

Ensure documentation of all follow-up and case resolution occurs including letter, education and/or corrective actions as directed by medical directors, CNO, or others.

Present cases for peer review, present QOC data trends/updates to QIC, and update to Credentialing and other groups as assigned.

Coordinate the department's preparation for regulatory audits including serving as the point of entry for audit readiness, supporting the development of any required Corrective Action Plans, monitoring and reporting readiness status, and escalating issues to CNO to address lack of progress or risk of non-compliance.

Utilize project management tools and resources to create work plans, tracking tools, and systems to ensure tracking of audit/survey readiness.

Responsible for coordination of the department's NCQA accreditation processes including coordination of assigning standards, monitoring and measuring progress, and ensuring evidentiary documentation is submitted with established time frames.  Additionally, ensure successful preparation for file review.

Assist with the development of the Annual Utilization Management Report by collecting data, supporting analytics, and writing of reports as directed by the CNO.



Bachelor's degree in nursing, social work, project management, data analytics or other health care related fields.  As appropriate, current and unrestricted Minnesota license required.

Required Experience

Two years or more experience in a managed care organization, quality management program in a health care setting or other related experience.


Preferred Experience

Experience in data collection, report writing, and basic data analytic skills.



UCare is proud to be a recognized Star Tribune Top Workplace for the 8th 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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