Appeals-Grievances Coordinator -Kelsey Seybold Remote in Pearland TX

UnitedHealth Group•Pearland, TX

17h•$20 - $36•Remote

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.

Requirements

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

Nice To Haves

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

Responsibilities

Analyzing eligibility data
Reviewing CMS transaction reports
Loading weekly files
Identifying errors
Optimizing workflows
Monitoring appeals and grievances for timeliness and accuracy
Ensuring documentation consistency
Training new Appeals & Grievances Coordinators
Handling complex cases, including multiple complaints, missed grievances, and appeals submitted to CMS
Aiding in creating, analyzing, and submitting reports for CMS audits and compliance monitoring, identifying trends in appeals and grievances
Supporting training development
Coordinating system updates
Collaborating with the Operations Trainer on documentation
Presenting cases during CMS audits
Recommending process improvements