Clinical Appeals and Grievances Specialist

Minneapolis, Minnesota
Dec 11, 2021
Feb 01, 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: Work from home

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 evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness and efficiency of specific services the organization has denied for prior authorization. Prepare, present and defend UCare's clinical decisions in State Appeals and Medicare Hearings with minimal involvement from the Medical Directors, fully support the medical directors with clinical research and recommendations, and fully support the non-clinical Appeals and Grievances (A&G) staff with complex medical necessity case review and letter reviews.

• Complete the initial review of medical necessity appeals within the established department turnaround times. Including, requesting relevant records, researching guidance, and making appropriate recommendations and routing service requests to medical directors for physician review for medical necessity review

• Utilize leadership skills for appeals and grievances and act as a resource for non-clinical and clinical team members

• Assist A&G non-clinical staff with reviewing letters and providing member friendly language verbiage for upheld medical necessity denial letters to ensure we are in compliance with NCQA requirements.

• Extrapolates and summarizes medical information for medical director, consultants and other external review

• Prepare, present and defend UCare's stance in State Appeal hearings and ALJ and MAC hearings for appeals that were denied due to medical necessity appeals

• Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.

• Develop a comprehensive knowledge of appeal and grievance State and Federal requirements including audit protocols and NCQA requirements

• Understand and support the organization's provider network and contracts.

• Document review activities in accordance with professional nursing and established organizational standards

• Participate in cross-departmental workgroups or teams as assigned.

• Collaborate with claims, Provider Relations and Contracting. Medical Directors and Utilization Review and other departments within UCare to resolve complex appeal and grievance clinical issues

• Prepare and send upheld medical necessity appeals to the IRE and work with A&G Manager, UM and pharmacy teams and Medical Directors to draft challenges for Maximus overturns

• Collaborate with QI and PRC to update yearly NQCA reports and work to identify barriers and implement interventions to annual goals

• Other projects and duties as assigned.


Registered Nurse, BSN preferred. Current and unrestricted Minnesota nursing license required.

Required Experience

Registered Nurse with experience in appeals and grievances and/or utilization review. Knowledge of utilization review standards/appeals and grievances standards and experience working with state and federally funded programs.

Preferred Experience

Experience in an HMO or MCO. Experience with presenting in State Appeals and/or Medicare hearings.


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: 12/10/2021

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