Clinical Compliance Specialist - UM Delegate Oversight

7 days left

Minneapolis, Minnesota
Jul 15, 2021
Aug 02, 2021
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.


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.




UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.


Working at UCare is more than 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. Employees join UCare and stay because of the opportunity to have a purpose-driven job.

Our strong culture has established UCare as a Star Tribune Top 150 Workplace for 12 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.


Position Description

This position is responsible for the oversight and evaluation of the Utilization Management (UM) processes of UCare's delegated entities. This includes comprehensive annual assessments and demonstrated ongoing oversight. Responsible for interpreting and applying state and federal regulations in performing operational assessments.

• Apply knowledge of State, Federal, and NCQA accreditation standards to assess and monitor the performance of delegated entities.

• Understand the UM processes within UCare and delegated entities in order to assess and evaluate their ability to comply with contractual obligations.

• Develop and implement auditing tools and strategies to fully analyze the ability of each delegated entity to achieve optimal compliance with regulatory standards and meet contractual obligations.

• Conduct delegated entity oversight meetings consisting of interviews, process reviews, chart audits, and review of other data to gain full understanding of the UM processes of each delegated entity.

• Write detailed reports that describe delegated UM processes and the results of audits conducted in accordance with contractual and regulatory requirements. Oversee completion of corrective action plans and other strategies to monitor the progress of each delegated entity on an ongoing basis. Escalate repeat audit findings, as appropriate, to leaders for action. Present findings as appropriate.

• Participate in pre-delegation assessments, as necessary, to ensure the entity has the capacity and capability to perform delegated functions. Prepare written reports of assessments and communicate results to leaders and delegated entities.

• Participate in internal and external audits as directed, including identification of a universe, gathering records, file preparation, and presenting information to auditors as requested.

• Coordinate and facilitate meetings with delegated entities to disseminate information, clarify processes, escalate compliance risk, and ensure corrective action as needed.

• Coordinate and implement compliance audits and other audits as directed. Prepare and implement a project plan, statement of work, and/or process flow related to different projects, and be able to prepare a basic results analysis.

• Develop and maintain positive relationships with delegated entities and other departments within UCare; ensure cooperation and compliance with regulatory requirements and UM processes. Provide ongoing support for delegated entities related to UM processes, including identification of educational needs, provision of basic training, references to regulatory requirements, etc.

• Prepare and respond to Request for Proposals (RFP), as needed.

• Assist in the preparation of annual audit results and summary.

• Serve as the Subject Matter Expert (SME) in workgroups or projects representing UM delegate oversight as directed.

• Lead process improvement initiatives to enhance efficiencies in delegates.

• Support training staff to serve as support for UM audits and monitoring.

• Other projects and duties as assigned.


Bachelor's degree: demonstrated experience may be considered in lieu of degree.

Required Experience

Five years' experience working in a health plan, preferably in utilization management, quality, and/or compliance. Required experience in working with and interpreting state and federally funded program benefits, including Medicare and Medicaid.

Preferred Experience

Experience applying NCQA, state, and federal regulatory standards to UM processes. Knowledge of delegation oversight. Experience with health care-related regulatory compliance, auditing, or surveying.


The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, 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.

JOB POST DATE: 07/14/2021

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