Optum · 10 hours ago
Appeals And Grievance Quality Analyst - Kelsey Seybold Clinic
Pearland, TX
Full-time
Onsite
Mid Level
$28.94/hr - $51.63/hr
3+ years expOptum is part of one of the nation's leading health care organizations, Kelsey-Seybold Clinic, offering coordinated and accountable care. The Appeals And Grievance Quality Analyst role involves leading quality reviews, addressing system issues, and supporting process improvements within the KelseyCare Advantage Operations Department.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Responsibilities include analyzing eligibility data, reviewing CMS transaction reports, loading weekly files, identifying errors, and optimizing workflows
The position monitors appeals and grievances for timeliness and accuracy, ensures documentation consistency, and trains new Appeals & Grievances Coordinators
It handles complex cases, including multiple complaints, missed grievances, and appeals submitted to CMS
The role aids in creating, analyzing, and submitting reports for CMS audits and compliance monitoring, identifying trends in appeals and grievances
It supports training development, coordinates system updates, and collaborates with the Operations Trainer on documentation
This position also presents cases during CMS audits and recommends process improvements
Qualification
Required
High School diploma or equivalent
3+ years of experience with Healthcare Appeals and Grievances
2+ years of 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
Epic Managed Care experience
Experience in Health Plan Operations in Healthcare Industry
Knowledge of CMS Audits
Ability to analyze and report on appeals and grievance trends and quality error rates
Benefits
A comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
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