Appeals and Grievances Regulatory and Compliance Specialist

Minneapolis, Minnesota
Apr 12, 2018
May 06, 2018
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 for the oversight and reporting of key quality and compliance components of appeals and grievances processes.  Ensure CMS, MDH & NCQA regulatory adherence by coordinating staff training, assists with policies, procedures, work instructions, letters, and perform compliance review of A&G processes and files. Develop and implement auditing strategies to assist with compliance reviews. Create compliance reports and participate in audit functions. Perform case work as directed by the A&G Manager.  Specific duties and responsibilities include:  

Audit appeals and grievances cases to ensure they are processed according to CMS, MDH & NCQA standards. 

Provide training to the Appeals and grievances staff to ensure all regulatory guidelines of the Appeals & Grievances process.

Assist in developing, implementing and maintaining appeals and grievances policies, procedures and work instructions.

Apply knowledge of State, Federal, NCQA guidelines and other regulating bodies to assist with appeals and grievances functions.

Maintain timely communication with manager or supervisor regarding Compliance 360 emails.

Serve as a resource specialist by attending work groups as assigned.

Assist with the yearly material reviews for appeals and grievances letters and complete the submission of letters.  Work with Materials to implement and communicate the letter changes to the Appeals and Grievances team.

Other projects and duties as assigned. 


Bachelor degree; experience in the health/insurance industry and with regulatory compliance.

Required Experience

Three years experience in a health plan or health care industry.  Demonstrated knowledge of appeal and grievance regulatory requirements. Compliance experience. Policy and procedure development experience.

Staff  development/training experience. Strong computer and reporting experience.  

Preferred Experience

Auditing experience.


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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