Requisition Number: 2339295
Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.
This position leads quality reviews for the KelseyCare Advantage Operations Department, including Appeals & Grievances, Enrollment, Premium Billing, Eligibility, Intake, and Regulatory Teams. It addresses system issues, troubleshoots problems, and collaborates with IT and management to resolve them. The role supports process improvements and ensures effective use of health plan information and CMS guidelines.
Responsibilities include analyzing eligibility data, reviewing CMS transaction reports, loading weekly files, identifying errors, and optimizing workflows. The position monitors appeals and grievances for timeliness and accuracy, ensures documentation consistency, and trains new Appeals & Grievances Coordinators. It handles complex cases, including multiple complaints, missed grievances, and appeals submitted to CMS. The role aids in creating, analyzing, and submitting reports for CMS audits and compliance monitoring, identifying trends in appeals and grievances. It supports training development, coordinates system updates, and collaborates with the Operations Trainer on documentation. This position also presents cases during CMS audits and recommends process improvements.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:

• High School diploma or equivalent
• 3+ years of experience with Healthcare Appeals and Grievances
• 2+ years of Medicare Advantage experience
• Knowledge of CMS Regulations including Appeals and Grievances, Enrollment, and Member Services.
• Knowledge of CMS regulations
• Knowledge and ability to Interpret/Apply CMS Coverage Rules regarding Appeals
• Knowledge of Appeals and Grievances reporting and audit requirements
• Demonstrated analytical skills including file format manipulation and data comparison

Preferred Qualifications:

• Epic Managed Care experience
• Experience in Health Plan Operations in Healthcare Industry
• Knowledge of CMS Audits
• Proven ability to analyze and report on appeals and grievance trends and quality error rates

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $20.38 to $36.44 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.