Appeals And Grievance Quality Analyst - Kelsey Seybold Clinic
About The Position
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. 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.
Requirements
- High School diploma or equivalent
- 3+ years of experience with Healthcare Appeals and Grievances
- 2+ years of Medicare Advantage experience
- Demonstrated analytical skills including file format manipulation and data comparison
- Demonstrated knowledge of CMS Regulations including Appeals and Grievances, Enrollment, and Member Services
- Demonstrated knowledge of CMS regulations
- Knowledge and ability to Interpret/Apply CMS Coverage Rules regarding Appeals
- Knowledge of Appeals and Grievances reporting and audit requirements
Nice To Haves
- Epic Managed Care experience
- Experience in Health Plan Operations in Healthcare Industry
- Knowledge of CMS Audits
- Ability to analyze and report on appeals and grievance trends and quality error rates
Responsibilities
- 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
Benefits
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
