Lead Provider Disputes Quality - Claims - 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. Primary Responsibilities: The Provider Disputes Quality Lead oversees quality assurance activities and daily operational support within the Provider Disputes team. This position ensures adherence to payer, CMS, and internal quality standards while maintaining consistency in documentation, processing accuracy, and policy compliance. The Lead performs case reviews, identifies trends and training opportunities, and partners with the Quality and Regulatory teams to maintain readiness for internal and external audits and conducts training when and wherever needed. This position also assists with recovery appeal integration, facilitates quality feedback for Analysts, and ensures policies, SOPs, and universes meet regulatory expectations. The role serves as a liaison between Provider Disputes, Claims Administration, Regulatory, and Quality teams to improve process efficiency and maintain compliance with payer requirements. 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
- 4+ years of direct Claims Processing, Provider Disputes, or Appeals experience in a Managed Care or Medicare Advantage environment
- Demonstrated experience in quality auditing or process review
- Working knowledge of payer contracts, dispute workflows, and reimbursement methodologies
- Proficiency in Microsoft Office (Excel, Word, Outlook, PowerPoint)
- Ability to interpret and apply payer contracts and CMS/TDI requirements
Nice To Haves
- Associate or Bachelor’s Degree
- Experience in a Quality Assurance or Lead capacity.
- Experience with Epic Tapestry, TriZetto / FACETS, or similar claims platforms
- Experience supporting internal/external audits and universe validation
- Training experience and familiarity with QA sampling methodologies
- Experience coordinating or supporting system upgrades, process redesign, or operational transitions
Responsibilities
- Oversees quality assurance activities and daily operational support within the Provider Disputes team.
- Ensures adherence to payer, CMS, and internal quality standards while maintaining consistency in documentation, processing accuracy, and policy compliance.
- Performs case reviews, identifies trends and training opportunities
- Partners with the Quality and Regulatory teams to maintain readiness for internal and external audits and conducts training when and wherever needed.
- Assists with recovery appeal integration
- Facilitates quality feedback for Analysts
- Ensures policies, SOPs, and universes meet regulatory expectations.
- Serves as a liaison between Provider Disputes, Claims Administration, Regulatory, and Quality teams to improve process efficiency and maintain compliance with payer requirements.
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements)
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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
