Appeals and Grievances Manager

Minneapolis, Minnesota
May 10, 2018
Jun 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 to ensure Appeals and Grievances processes are effectively and efficiently implemented for all UCare products.  This includes management of daily operations, performance management of designated staff, achievement of regulatory timelines, and oversight of critical issues.  Provide oversight for the creation and maintenance of policies and procedures and provide required reports to internal committees and external regulatory agencies.  Specific duties and responsibilities include:   

Understand and implement regulatory requirements for resolution of appeals and grievances received from UCare members or their authorized representatives. Maintain close working relationship with Government Programs, Customer Services, and Compliance to coordinate and implement regulatory changes.

Oversee the development of policies and procedures, in coordination with other departments and the UCare guidelines, to ensure UCare's Appeals and Grievances processes meet regulatory requirements.

Ensure appeals and grievances are managed and resolved according to regulations and related policies and procedures.  Communicate with other departments and the Medical Directors as necessary to complete Appeals and Grievances investigations in a timely manner, including expedited processing as warranted.

Communicate with other UCare Departments, including Provider Network Management, Government Programs, Clinical Services, Claims, Marketing, Quality Management and Customer Services to ensure UCare complies with Appeals and Grievances regulations and is responsive to member grievances.

Hire and oversee designated appeals and grievances staff.  Ensure cases are completed timely.  Train, mentor and coach members from the team including maintaining daily schedules, productivity and workflow.  Schedule regular 1:1 meetings with designated appeals and grievances staff to provide feedback and identify staff development opportunities to enhance the knowledge and skills of staff. 

Ensure tools required to process Appeals and Grievances are available and meet staff needs. Oversee processes required to implement enhancements to the Appeals and Grievances database.

Oversee and manage high-risk, high-visibility Appeals and Grievances cases and ensure appropriate resources are utilized to achieve resolution.

Provide accountability for internal Appeals and Grievances compliance reviews. Represent the Appeals and Grievances function during regulatory and accrediting audits.  Ensure required Corrective Action Plans (CAPs) effectively address the root cause of the finding and are completed within the designated timeframe. Ensure CAP training and required monitoring are completed.

Identify process improvement opportunities or reoccurring issues identified through the management of member complaints, appeals or grievances.  Escalate these issues as necessary and participates in developing and implementing solutions.

Serve as Appeals and Grievances representative or name delegate for committees and implementation teams that relate to Appeals and Grievances activities.  Serve and participate in other interdepartmental committees and work groups as assigned.

Oversee the completion of annual Appeals and Grievances volume and trend reports for appropriate committees. Ensure Appeals and Grievances data is reported to regulators and others as required or requested.

Ensure Appeals and Grievances-related reports (e.g., PCC Quarterly Complaint Report, trend report to QIC, etc.) are appropriately assigned, completed, and disseminated.

Ensure appropriate oversight when Appeals and Grievances responsibilities are delegated to a business entity.  Collaborate with Delegated Business Services to ensure appropriate procedures are followed and reports made.  Coordinate and participate in annual audits of delegated entities.

Manage Appeal and Grievances cases to maintain daily workflow, regulatory timelines, and complex case resolution.

Other projects and duties as assigned. 


Bachelor's degree in a health related field; demonstrated experience in the health/insurance industry may be considered in lieu of degree.

Required Experience

Three years management experience.  Five years experience working in a health plan, insurance industry or health care facility.

Preferred Experience

Clinical background highly desirable, nursing preferred.  Two years of customer service experience.  Knowledge of grievance and appeal regulatory requirements preferred.


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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