Appeals & Grievances Federal Specialist

Minneapolis, Minnesota
Mar 29, 2023
Apr 18, 2023
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 600,000 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 200 Workplace for 13 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

Position Description

This position is responsible for operational and administrative tasks related to the appeals and grievances (AG) process for Medicare and DNSP products. Responsibilities include coordinating the investigation, identification, documentation and resolution of appeals and grievances in a timely manner according to regulatory timelines. Collaborate directly with members and providers to obtain information and de-escalate issues of members. Represent UCare in Administrative Law Judge (ALJ) Hearings and Medicare Advisory Committee (MAC) hearings for all types of second level appeals.

• Analyze, answer, resolve and document telephone calls from members, providers, internal departments, and external agencies, according to Federal, State and Commercial regulatory timelines.

• Provide accurate, prompt and courteous service in response to grievances and appeals.

• Investigate and conduct research in order to evaluate, respond to, and close claims and service appeals in accordance with State, Federal and Commercial regulatory timelines.

• Prepare second level reviews for submission to the Maximus Federal Services. Participate and represent UCare in ALJ and MAC hearings.

• Utilize critical thinking skills to gather information, apply sound reasoning and draw appropriate conclusions for all Medicare lines of business. Recommend business decisions to leadership for case as needed.

• Utilize organization and prioritize cases with a variety of timelines to ensure all timelines are met according to Federal regulatory timelines.

• Represent UCare in ALJ and MAC hearings for all types of second level appeals. Prepare case file by collecting information, contacting providers for additional information, and sending all necessary case materials to Maximus Federal Services.

• Respond promptly to Maximus requests for additional information, Part D case file requests and effectuating overturned cases with all Maximus information, effectuate all overturned cases to ensure STARs ratings are maintained.

• Manage a large variety of case types for Medicare and DSNP members including Part C Claim and Service appeals, Grievances, Part D, ALJ and MAC hearings and prepare and present cases to Medical Directors, Pharmacists and leadership as needed for case resolution.

• Rotate shifts for weekend monitoring of CTMs, phones, e-mail and fax queue for urgent or expedited requests.

• Monitor, investigate and resolve CTM complaints

• Participate in cross departmental meetings and workgroups as a subject matter expert in CMS appeals and grievances.

• Regularly review Chapter 13, Chapter 18, Medicare Managed Care Manual, Medicare LCD/NCD, EOC and NCQA requirements to ensure understanding of case requirements. Work closely with Federal Compliance Lead when questions arise.

• Provide Appeals and Grievances Intake Back-Up support, as needed, in the event of high volume, PTO, or unplanned absences.

• Other projects and duties as assigned


Bachelor's degree in health-related field or equivalent; demonstrated experience may be considered in lieu of degree.

Required Experience

Experience with Medicare, Medicaid & Commercial benefit programs. Demonstrated experience in completing clear and meaningful written and verbal communication.

Preferred Experience

Experience answering benefit and claim questions. Claims adjudication process experience. Experience in pharmacy utilization review. Amisys experience and proficiency in Microsoft Office program - Word, Excel and Access.


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: 2/24/2023

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