Responsibilities

This position monitors appeals and grievances for timeliness and completion, ensures consistency of documentation of claims, lead quality review of work by the KelseyCare Advantage Appeals and Grievances Department and trains new Appeals and Grievances Coordinators. This position aids in the discovery, recommendation, and implementation of new processes to aid in the dissemination and utilization of vital Health plan information and CMS guidelines including creation of training materials including running reports to identify trends in appeals and grievances. This position will process appeals and grievances for members with complex issues including handling cases received by members who file multiple complaints and process missed grievances identified on the Member Services Call Log reviews and assist others in uploads of appeals submitted to CMS. This position is responsible for aiding in the creation and analysis of reports related to CMS audits and Compliance monitoring submission as well as presenting cases in CMS audits.

Job Title: Appeals and Grievance Quality Analyst

Clinic Location: Pearland Administrative Office Building

Department: Kelsey Care Plan Advantage Operations

Job Type: Full Time

Salary Range: $53,123.00 – $65,624.00 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

Qualifications

Education

Required: High School diploma or equivalent

Preferred: Some college or technical school

Experience

Required: 3-5 years’ experience with Healthcare Appeals and Grievances. 2 years Medicare Advantage experience. Demonstrated analytical skills including file format manipulation and data comparison. Demonstrated knowledge of CMS Regulations including Appeals and Grievances, Enrollment, and Member Services.
Demonstrated knowledge of CMS regulations. Knowledge and ability to Interpret/Apply CMS Coverage Rules regarding Appeals. Knowledge of Appeals and Grievances reporting and audit requirements

Preferred: Ability to analyze and report on appeals and grievance trends and quality error rates. Prior Epic Managed Care experience. Prior experience in Health Plan Operations in Healthcare Industry. Knowledge of CMS Audits

License(s)

Required: N/A

Preferred: N/A

Special Skills

Required: Excellent Written and Verbal Communication Skills. Strong Analytical Skills. Proficient in Microsoft Office Suite, including Excel, Access, Word, Power Point, and Outlook. Excellent written and verbal communication skills.

Preferred: Strong Written and Verbal Communication Skills.

Other

Required: Ability to read and interpret technical reports. Run reports and provide feedback to appropriate personnel. Be flexible, able to work overtime as needed.
Detail oriented, and work with minimum supervision to meet strict deadlines.

Preferred: Some experience in Training

Working Environment: Office

About Us

Start your career journey and become a part of a community of renowned Healthcare professionals. Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties. Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner. Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares.

Why Kelsey-Seybold Clinic?

• Medical, Vision, and Dental
• Tuition Reimbursement
• Company Matching 401K
• Employee Reward and Recognition Program
• Paid time off for vacation, sick, and Holidays
• Employee Assistance Program
• Continuing Medical Education allowance