- Audit appeals and grievances cases to ensure they are processed according to DHS, CMS, MDH & NCQA standards. Provide weekly results to AG leadership.
- Mentor and assist with training and onboarding new team members in appeals and grievances. Support specialists as they are learning new case types, including presenting cases at State Fair Hearings (SFH).
- Hold weekly State QA meetings with the State Specialist team to answer question and provide QA guidance and SME support.
- Identify and research trends or issues and recommend changes to enhance appeals and grievances processes. Identify knowledge gaps and training opportunities to enhance staff performance.
- Responsible for updating work instructions, policies and procedures and letters for all State appeals and grievances.
- Serve as a primary resource for Appeals and Grievances requirements for DHS related questions for internal staff and all departments at UCare. Collaboratively work with State Government Relations, Legal, DHS, NCQA to confirm guidance, as needed. Use system to log regulatory updates for the team's reference.
- Keep current on appeals and grievances case processing and intake processes by maintaining a small caseload and serving as a backup for staff as they are out of the office or as needed during times of high volumes. Assist with escalated, complex cases and late referrals by reporting to A&G leadership.
- Complete DHS reporting and support CMS reporting, as needed
- Accurately interpret incoming appeals and grievances to assist with determining the validity of cases by utilizing health plan member certificates of coverage, provider contracts, state and federal rules and regulations, and UCare policies and procedures.
- Participate in cross departmental meetings and workgroups as the A&G subject matter expert. Collaborate with other UCare departments, committees, and external departments on process improvements. Provide updates to AG leadership and to the team regarding the meetings/workgroups.
- Report late referrals and possible compliance concerns to AG Leadership.
- Attend all State GR meetings and maintain excellent understanding of requirements.
- Collaborate with AG leadership to effectively communicate compliance requirements to all stakeholders and create periodic update briefs and educational tools and resource to increase AG staff knowledge of the healthcare regulatory environment.
- Use and maintain Compliance 360 to ensure timely documentation of identified issues as well as provide updates on assigned activities according to deadlines. Develop workflows and track implementation progress for new regulatory guidance.
- Assist with the yearly material reviews for appeals and grievances letters and complete the submission of letters. Work with Materials to implement and communicate the letter changes to the Appeals and Grievances team.
- Other projects and duties as assigned.#J-18808-Ljbffr
-
Quality Assurance Specialist
2 weeks ago
Internet Brands Minneapolis, United States· Job Description: Quality Assurance Specialist · Job Type: Full Time · Basic Job Function: · The Quality Assurance Specialist is responsible for monitoring, inspecting, and analyzing interactions for our outbound/inbound contact center. Ensuring the delivery of excellent cus ...
-
Quality Assurance Specialist
3 weeks ago
Kerecis Minneapolis, United StatesJob Type · Full-time · Description · The Quality Assurance Specialist supports the project teams during the development process of new products and supports existing products when necessary. They are required to comply with Good Manufacturing Practices, ISO requirements, and o ...
-
Case Management Quality Assurance Specialist
3 weeks ago
Placement Partners Minneapolis, United StatesJob Description Job Description About UsPlacement Partners provides community-based vocational, residential, and case management services to adults with developmental disabilities, TBI, and others requiring assistance to work and live independently. We are committed to diligently ...
-
Remote Quality Assurance Specialist- Healthcare
3 weeks ago
TEKsystems Minneapolis, United States:This role will have the responsibility of quality testing all of the benefit plans for Prime. They will work in tandem with the AIS team as they build the plan. This person will then be working within a few systems to make sure the plan is built out correctly and to the specs of ...
-
Quality Assurance Specialist
3 weeks ago
Element Materials Technology Acton, United StatesOverview: · Element Materials Technology Boston-Acton, Inc. is looking for a full-time Quality Assurance Specialist to support the Quality Assurance Unit in a cGMP Microbiology Laboratory · Responsibilities: Comply with current Good Manufacturing Practice regulations, Good Docu ...
-
Senior Data Quality Assurance Specialist
1 week ago
College Possible Saint Paul, United States Regular, Full timeSenior Data Quality Assurance Specialist · College Possible - National · About College Possible: · As one of the largest and most successful college access and success organizations in the country, since 2000 College Possible has empowered more than 85,700 students on their path ...
-
Quality Assurance Specialist
2 weeks ago
Ferrero Bloomington, United StatesCompany Description: · Ferrero is a family-owned company with a truly progressive and global outlook and iconic brands such as Nutella, Tic Tac, Ferrero Rocher, Raffaello, Kinder Bueno and Kinder Surprise. As the love for our brands continues to grow, so too does our global reach ...
-
Quality Assurance Specialist
2 weeks ago
Defense Contract Management Agency Bloomington, United States Full timeServes as a Quality Assurance developmental intern within DCMA. · Completes classroom and on-the-job training to acquire, exercise, and maintain knowledge of the duties inherent quality assurance mission support activities. · Observes and assists with quality or manufacturing sur ...
-
Quality Assurance Specialist
1 week ago
FERRERO Bloomington, United States**Company Description**: · Ferrero is a family-owned company with a truly progressive and global outlook and iconic brands such as Nutella, Tic Tac, Ferrero Rocher, Raffaello, Kinder Bueno and Kinder Surprise. As the love for our brands continues to grow, so too does our global r ...
-
Quality Assurance Specialist
5 days ago
FERRERO Bloomington, United States**Company Description**: · Ferrero is a family-owned company with a truly progressive and global outlook and iconic brands such as Nutella, Tic Tac, Ferrero Rocher, Raffaello, Kinder Bueno and Kinder Surprise. As the love for our brands continues to grow, so too does our global r ...
-
Quality Assurance Specialist
1 month ago
Ferrero Bloomington, United StatesCompany Description: · Ferrero is a family-owned company with a truly progressive and global outlook and iconic brands such as Nutella, Tic Tac, Ferrero Rocher, Raffaello, Kinder Bueno and Kinder Surprise. As the love for our brands continues to grow, so too does our global reach ...
-
Case Management Quality Assurance Specialist
2 weeks ago
Placement Partners Hopkins, United StatesCase Management Quality Assurance Specialist · Full Time · Professional · Edina, MN, US · 7 days ago · Requisition ID: 1352 · Salary Range: · $22.00 To 25.00 Annually · About Us · Placement Partners provides community-based vocational, residential, and case management se ...
-
Quality Assurance Specialist
2 weeks ago
Twin City Staffing Anoka, United StatesEmbark on a challenging and rewarding career as a quality assurance specialist with Twin City Staffing. Located in the Coon Rapids, MM area. We are seeking an individual with a keen eye for detail and a passion for maintaining and improving overall quality system processes. This ...
-
Quality Assurance Specialist
3 weeks ago
Twin City Staffing Anoka, United StatesEmbark on a challenging and rewarding career as a quality assurance specialist with Twin City Staffing. Located in the Coon Rapids, MM area. We are seeking an individual with a keen eye for detail and a passion for maintaining and improving overall quality system processes. This ...
-
Case Management Quality Assurance Specialist
3 weeks ago
Placement Partners Edina, United StatesCase Management Quality Assurance Specialist · Full Time · Professional · Edina, MN, US · 7 days ago · Requisition ID: 1352 · Salary Range: · $22.00 To 25.00 Annually · About Us · Placement Partners provides community-based vocational, residential, and case management servic ...
-
HRIS QA Lead
1 week ago
Strategic Education Minneapolis, United States Full timeResponsibilities: · Develop, implement, and oversee quality assurance (QA) and testing strategy and processes to ensure that HR Tech products (solutions, data/audit, security) meet required specifications for quality, function, and reliability prior to delivery. · Work with proj ...
-
Software Engineer
2 weeks ago
Agility Partners Minneapolis, United StatesThe Commercial Digital Integration team is seeking a Lead level Integration Engineer to develop common reusable integrations across all customer facing Channels for Commercial Customers. You will work directly on an Agile scrum team in close partnership with business product team ...
-
Radiologic Technologist
1 week ago
RAYUS Radiology St. Louis Park, United States Full timeThere is a $3,000 relocation or sign on bonus for this role RAYUS Radiology, formerly Center for Diagnostic Imaging, is looking for a Float C-arm Technologist to join our team. As a Float C-arm Technologist, you will operate a C-arm in assigned modality to produce images of the p ...
-
Business Accountability Specialist
1 week ago
WELLS FARGO BANK Minneapolis, United States Full timeAbout this role: · Wells Fargo is seeking a Business Accountability Specialist in the Corporate Plans Investment Team (CPIT) as part of Wealth & Investment Management (WIM). In this role, you will be responsible for reporting including data quality and accuracy, maintaining contr ...
-
Grants Specialist
3 weeks ago
Ebenezer Minneapolis, United StatesOverview · The Grants Specialist is a member of the Non-Research Government Grants and Sponsored Projects function and will plan an active role in the development, execution, and management of efforts in support of grant revenue growth. This individual works closely with service ...
Appeals & Grievances State Quality Assurance Specialist - Minneapolis, United States - Ucare Minnesota
![Default job background](https://contents.bebee.com/public/img/bg-user-ex-1.jpg)
Description
ABOUT UCAREUCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry.
WORKING AT UCAREWorking 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 DescriptionAs the Appeals and Grievances (A&G) State Quality Assurance Specialist, you will be responsible for the oversight of key quality and compliance components of the appeal and grievances processes.
You will ensure Centers for Medicare and Medicaid Services (CMS), Minnesota Department of Health (MDH) & NCQA regulatory adherence by coordinating staff training; contributing to creating and/or updating policies, procedures, work instructions and letters; and perform compliance reviews of A&G processes and files.
In partnership with the A&G Senior Manager, create, develop and implement audit strategies to assist with compliance reviews. Perform case work as directed by the A&G Senior Manager.