Appeals and Grievances Coordinator - Kelsey Seybold -Remote in Pearland

Requisition number: 2399675

Job category: Claims

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 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.

This role offers remote work for candidates based in Houston TX

Primary Responsibilities:

• Performance:

• Conducts independent research on all Medicare Advantage Appeals and Grievances, both expedited and standard, adhering to department policies and procedures within regulated timeframes. This includes thoroughly reviewing and exploring all avenues to obtain relevant case information independently before escalating for research response

• Handles difficult customer calls concerning appeals or quality issues effectively, ensuring customer satisfaction and resolution of concerns

• Processes complex appeals and grievances, including those involving multiple filings by members or cases highlighted on Call Log Reports or from other documentation systems

• Prepares accurate and error-free response letters for appeals and grievances following regulatory guidelines

• Facilitate the uploading of appeals to Maximus and serve as a point of contact for Maximus Request of Information (RFIs) and other correspondences

• Escalates issues to the People Leader promptly to mitigate gaps in cases and reduce compliance risks

• Actively engages in case management by minimizing gaps and frequently updating cases in line with the established department process, being 100% for all actions taken on cases owned up, through closure

• Takes full responsibility for case ownership, including surveying all elements of the role for compliance, such as checking for CTMs during on-call weekends and actively seeking leader assistance for case review or clinical team contact for reviews

• Timelines:

• Meets or exceeds timeliness expectations to deliver 100% complete and compliant cases by the closure of the request

• Strives to meet or exceed production standards, ensuring timely and efficient handling of cases

• Compliance Quality:

• Ensures complete and compliant case closure according to internal and CMS regulations, including attaching all notes and documentation to the case and saving them in required shared locations

• Collects and organizes documentation and evidence for investigations, exhausting all independent research avenues before external outreach

• Internal Quality:

• Maintains accurate documentation of all actions within the appeals and grievances cases, in accordance with department policy and procedures, including internal timeframes

• Stays vigilant of caseload using provided reports and system resources like notifications and dashboards to ensure adherence to internal timeframes and quality standards

• Other:

• Assists in training on pilot, new, or existing processes for both existing and new hires within the team

• Participates in CMS audits as required

• Contributes to special projects and undertakes additional duties as assigned, demonstrating flexibility and commitment to the organization's broader needs

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.

Required Qualification:

• 1+ years Managed Care experience in a managed care environment working with appeals and grievances

Preferred Qualifications:

• 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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. 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. The hourly pay for this role will range from $20 - $36 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.