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

UnitedHealth Group•Pearland, TX

2d•$20 - $36•Onsite

About The Position

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.

Requirements

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.

Nice To Haves

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

Responsibilities

Actively manages all Medicare reconsiderations, grievances, and appeals, adhering to company policies and CMS regulatory requirements.
Serves as the primary liaison for the CMS regional office regarding appeals, grievances, and complaints.
Researches, tracks, and orchestrates the resolution of medical and prescription drug appeals and grievances.
Plays a key role in CMS Audits.
Coordinates complaint resolutions with all delegated parties.
Meticulously prepares and presents cases.
Creates and generates requisite reports in line with CMS regulatory requirements.
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.
Works autonomously under strict deadlines.
Identifies and analyzes trends and emerging issues, subsequently recommending effective solutions.
Develops and delivers training and resources to meet both Corporate and CMS regulatory standards.