Appeals & Grievances (AG) State Specialist

1 week ago

Minneapolis, Minnesota, United States UCare Minnesota Full time

ABOUT UCARE
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
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 14 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


As an Appeals and Grievances (AG) State Specialist, you will be responsible for operational and administrative tasks related to the appeals and grievances (AG) process for State and DSNP 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 State Appeals Hearings (formerly State Fair Hearings).

  • Analyze, answer, resolve, and document telephone calls from members, providers, internal departments, and external agencies, according to State, Federal or Commercial regulatory timelines.
  • Provide accurate, prompt and courteous service in response to members and providers on all 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 Department of Human Services (DHS). Participate and represent UCare in State Appeal hearings.
  • Utilize critical thinking skills to gather information, apply sound reasoning and draw appropriate conclusions for State Program lines of business. Recommend business decisions to leadership for cases as needed.
  • Utilize organization and prioritize cases with a variety of timelines to ensure all timelines are met according to State, Federal and Commercial regulatory timelines.
  • Manage a large variety of case types for State and DSNP members including Claim and Service appeals, Grievances, hearings and prepare and present cases to Medical Directors, Pharmacist and leadership as needed for case resolution.
  • Partner with Legal Aid, Ombudsmen and the Department of Human Services when investigating and resolving State Appeals.
  • Rotate shifts for weekend monitoring of, phones, e-mail and fax queue for urgent or expedited requests.
  • Regularly review State Contract language, State Laws, MCHP manual, member handbook and NCQA requirements to ensure understanding of case requirements. Work closely with DHS compliance coordinator when questions arise.
  • Provide Appeals and Grievances Intake Back-Up support, as needed, in the event of high volume, PTO and/or unplanned absences.
  • Other projects and duties as assigned

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