Regulatory Compliance Lead

7 days left

Minneapolis, Minnesota
Oct 13, 2021
Jan 25, 2022
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.


Work Location: In the office, work from home, or hybrid (in the office 3 or more days per week)

The health and safety of our employees, members, providers, and our community is our highest priority. Therefore, all new employees are expected to be fully vaccinated against COVID-19 prior to starting at UCare, subject to limited exceptions such as for a sincerely held religious belief or for medical reasons.

Position Description

This position is responsible to lead efforts to manage aspects of certain CMS, State, and other regulatory audits from preparation through post-audit activities by collaborating with the department and internal departments. Maintain a compliance oversight program designed to ensure that UCare's data submissions to government agencies for risk adjustment payments based on diagnoses are compliant with applicable laws, regulations and contract requirements.

• Manage participation in certain government audits by actively managing government expectations, determining requirements, leading auditors to accurate conclusions.

• Work directly with regulatory auditors (or vendors hired by regulatory bodies to perform the audit).

• Work directly with other internal departments (operational departments as well as within the Compliance Department) to prepare for and respond to various regulatory audits.

• Facilitate readiness with internal departments by thoroughly understanding and communicating various audit protocols, reviewing universe data submissions, conducting readiness and risk assessment activities, and leading various aspects of audit logistics.

• Maintain files and documentation of audit activities, document requests and submissions, communication, notes, results (findings and non-findings) and any resulting corrective action.

• Maintain and direct a risk adjustment compliance oversight program that addresses risk adjustment data collection and reporting by UCare's internal operations, contracted providers and any of UCare's vendors involved in risk adjustment functions.

• Maintain and direct a risk adjustment auditing and monitoring program, based in part on data mining identifying high-risk submissions or providers and review of submitted diagnosis codes and supporting medical charts.

• Collaborate with other internal departments such as Health Care Economics, Government Relations, and Provider Relations & Contracting, in the development of policies and procedures related to risk adjustment processes and audit readiness.

• Lead the cross-departmental Risk Adjustment Data Compliance Team (or similar committee).

• Collaborate with internal departments to conduct risk adjustment readiness assessments including an analysis of UCare's readiness for a CMS risk adjustment data validation audits (or similar audits by other government agencies as applicable) and provide recommendations to management for strengthening UCare's program.

• Participate in risk adjustment data validation audits by government agencies or outside audit vendors, providing assistance to internal stakeholders and conduct medical record chart reviews to validate diagnoses.

• Supervise the day-to-day work of one staff member, the Risk Adjustment Compliance Specialist, in furtherance of the risk adjustment compliance oversight program. Either directly or through the Risk Adjustment Compliance Specialist, ensure the following duties are carried out:

o Conduct medical chart reviews to validate submitted codes.

o Perform claims and medical record reviews with focus on accuracy of diagnoses, as needed to respond to particular issues, as part of regulatory audit, or as element of compliance oversight.

o Participate in the development and maintenance of internal chart review guidelines to ensure the accuracy of HCC diagnoses captured and submitted to CMS.

o Participate in the development and delivery of provider educational materials related to compliant coding and risk adjustment practices.

• Maintain knowledge of risk adjustment regulatory requirements and serve as an internal resource for departments in implementing coding and process changes needed to meet compliance.

• Other projects and duties as assigned.


Bachelor's degree in a related field; demonstrated experience may be considered in lieu of degree.

Required Experience

Five years related experience in a regulatory audit role in a health care setting. Experience with regulatory audits such as CMS Program Audits, CMS Data validation audits, Medicaid audits, etc. Experience with Medicare Risk Adjustment activities. General knowledge of coding, billing and compliance including Medicare coding requirements.

Preferred Experience

Comprehensive involvement with CMS Program Audits, CMS Data Validation audits, Medicaid audits, etc. Experience with CMS Medicare Advantage Risk Adjustment Data Validation audits. Experience in conducting audits and medical record reviews.


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: 10/12/2021

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