Appeals Grievances & Dispute Analyst Team Lead
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.
The Appeals & Grievances and Disputes Analyst Team Lead serves as the operational point person and analytical resource for the Appeals & Grievances and Disputes team, supporting daily operations and assisting the Supervisor with inventory oversight, work prioritization, regulatory compliance, and escalation management. Working with minimal guidance, this position analyzes moderately complex operational and regulatory issues, identifies solutions to non-standard requests and problems, and translates regulatory and business requirements into effective operational practices.
The position performs detailed analysis and validation of appeals, grievances, and disputes data, including CMS and health plan reporting universes, to identify data gaps, processing errors, compliance risks, and operational trends. The Analyst Team Lead also supports regulatory audits and requests for information, coaches and guides team members, and provides management with accurate information and recommendations to support timely, compliant, and high-quality outcomes.
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 Qualifications:
- High school diploma or equivalent
- 4+ years of directly related Medicare Advantage, managed care, regulatory operations, or appeals, grievances, and disputes experience may be considered in lieu of post-secondary education
- 3+ years of progressively responsible experience in Medicare Advantage, managed care, health plan operations, or appeals, grievances, and disputes
- Experience researching, processing, or reviewing complex appeals, grievances, disputes, complaints, or other regulated healthcare cases
- Experience monitoring workloads, regulatory timeframes, case documentation, or operational reports
- Experience serving as a subject matter resource, training or mentoring employees, or providing day-to-day workflow support
- Proven ability to collaborate effectively with leadership, clinical teams, Compliance, Pharmacy, Claims, Member Services, delegates, providers, and other operational areas
- Proven ability to work additional hours when necessary to meet regulatory deadlines, support audits, or address urgent operational needs
Preferred Qualifications:
- Relevant certification in healthcare compliance, quality, data analytics, project management, or process improvement
- 5+ years of Medicare Advantage appeals, grievances, and disputes experience
- Experience analyzing CMS reporting universes, validating regulatory data, or supporting CMS program audits
- Experience with quality assurance, root-cause analysis, process improvement, or corrective action activities
- Experience with Medicare Parts C and D appeals and grievances, CMS Complaints Tracking Module cases, disputes processes, or Independent Review Entity processes
- Experience with Epic, Tapestry, CRM applications, CMS systems, Microsoft Access, or similar case-management and reporting tools
- Experience importing, exporting, reconciling, or validating data from multiple sources
- Working knowledge of CMS reporting requirements and audit protocols applicable to Medicare Advantage appeals, grievances, and disputes
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 salary for this role will range from $60,200 - $107,400 annually 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 make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
OptumCare is 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.