Appeals and Grievances Coordinator - Kelsey Seybold Clinic - Pearland Business Office

Medicare Appeals, Grievances, and Complaints Manager

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 role actively manages all Medicare reconsiderations, grievances, and appeals, adhering to company policies and CMS regulatory requirements. As the primary liaison for the CMS regional office regarding appeals, grievances, and complaints, this individual diligently research, tracks, and orchestrates the resolution of medical and prescription drug appeals and grievances and plays a key role in CMS Audits. The role involves coordinating complaint resolutions with all delegated parties and meticulously preparing and presenting cases, alongside creating, and generating requisite reports in line with CMS regulatory requirements.

The individual in this position fosters solid working relationships and collaborates closely with various management staff across the organization, including the Medical Director, Clinic Operations Management, Part D Management, and Contracting, to ensure compliance with CMS Regulations in processing Appeals & Grievances. This role demands the ability to work autonomously under strict deadlines and involves identifying and analyzing trends and emerging issues, subsequently recommending effective solutions. This person is also responsible for developing and delivering training and resources to meet both Corporate and CMS regulatory standards.

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:

• Bachelor's degree or equivalent experience or combination of education and experience.
• 1+ years Managed Care experience in a managed care environment working with appeals and grievances

Preferred Qualifications:

• Associate or bachelor's Degree
• Medicare Advantage experience processing quality of care complaints, internal and external expedited appeals, and IRE determinations
• Medicare Part D experience
• Process Improvement Experience and ability to proactively identify issues and /problems
• Working experience Microsoft Access and Excel
• EPIC' Tapestry Experience
• Knowledge of claims and coding
• Proven effective organizational skills, and ability to work independently

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). The hourly pay for this role will range from $20 - $36 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.