Manager, Medical Management & Regulatory Operations - Kelsey Seybold Clinic - Pearland

UnitedHealth Group•Pearland, TX

4d•$91,700 - $163,700

About The Position

Provides leadership and operational oversight for Medical Management support operations, Coordination of Benefits (COB), Regulatory Reporting, Enrollment Data Validation (EDV), and Quality Assurance activities supporting Medical Management, Appeals & Grievances, Provider Disputes, Enrollment, and related health plan operations. Directs day-to-day operations involving referral navigation, incomplete referral resolution, home health referrals, DME referrals, and other specialty referral workflows while ensuring compliance with CMS regulations, health plan requirements, accreditation standards, and internal operational policies. Oversees COB operations responsible for validating and maintaining accurate member other insurance coverage information to support claims processing, authorization reviews, payment integrity, and coordination with external payers. Leads regulatory reporting, universe management, data validation, audit preparation, and reporting activities including the review, scrubbing, reconciliation, and submission of operational universes and regulatory data for Appeals & Grievances, Provider Disputes, Enrollment, Medical Management, and related operational areas. Provides leadership and oversight for Quality Assurance functions supporting Appeals & Grievances, Enrollment, Provider Disputes, and Medical Management operations, including quality review processes, operational monitoring, trend analysis, and identification of compliance or workflow gaps. Oversees staff responsible for quality auditing, universe review, regulatory reporting validation, and operational accuracy monitoring to ensure compliance, data integrity, and timely reporting. Partners collaboratively with operational and executive leadership to improve workflows, strengthen regulatory compliance, support audit readiness, streamline operational processes, and implement continuous improvement initiatives that enhance operational performance, timeliness, payment accuracy, provider and member experience, and overall organizational effectiveness. 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

Master’s Degree
5+ years of overseeing Healthcare Enrollment, COB and regulatory compliance with knowledge of CMS regulations and compliance standards
5+ years of leadership experience in quality assurance improvement, or operational compliance within a managed care environment
Solid knowledge of HMO, PPO, and POS plan types including Medicare and commercial health plans
Proven excellent written and verbal communication skills with Strong organizational skills and ability to follow through with multiple projects

Nice To Haves

5+ years of EPIC Experience
3+ years of working in or with Medical Management
3+ years of Healthcare and regulatory experience
1+ years of Quality Assurance experience
Experience with CMS MARx system

Responsibilities

Provides leadership and operational oversight for Medical Management support operations, Coordination of Benefits (COB), Regulatory Reporting, Enrollment Data Validation (EDV), and Quality Assurance activities supporting Medical Management, Appeals & Grievances, Provider Disputes, Enrollment, and related health plan operations.
Directs day-to-day operations involving referral navigation, incomplete referral resolution, home health referrals, DME referrals, and other specialty referral workflows while ensuring compliance with CMS regulations, health plan requirements, accreditation standards, and internal operational policies.
Oversees COB operations responsible for validating and maintaining accurate member other insurance coverage information to support claims processing, authorization reviews, payment integrity, and coordination with external payers.
Leads regulatory reporting, universe management, data validation, audit preparation, and reporting activities including the review, scrubbing, reconciliation, and submission of operational universes and regulatory data for Appeals & Grievances, Provider Disputes, Enrollment, Medical Management, and related operational areas.
Provides leadership and oversight for Quality Assurance functions supporting Appeals & Grievances, Enrollment, Provider Disputes, and Medical Management operations, including quality review processes, operational monitoring, trend analysis, and identification of compliance or workflow gaps.
Oversees staff responsible for quality auditing, universe review, regulatory reporting validation, and operational accuracy monitoring to ensure compliance, data integrity, and timely reporting.
Partners collaboratively with operational and executive leadership to improve workflows, strengthen regulatory compliance, support audit readiness, streamline operational processes, and implement continuous improvement initiatives that enhance operational performance, timeliness, payment accuracy, provider and member experience, and overall organizational effectiveness.