Responsibilities

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 strong 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.

Job Title: Appeals & Grievances Coordinator

Location: Pearland Administrative Office

Department: KS Plan Advantage-Operations

Job Type: Full Time

Salary Range: $50,724 - $62,659 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

Qualifications

Education

Required: Bachelor’s degree or equivalent experience or combination of education and experience.

Preferred: Associate or bachelor’s Degree

Experience

Required: 1-2 years Managed Care experience in a managed care environment working with appeals and

grievances.

Preferred: 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.

License(s)

Required: N/A

Preferred: Knowledge of claims and coding.

Special Skills

Required: PC skills, Word, Excellent Data Entry Skills,

Type 30 WPM

Preferred: Effective organizational skills, and ability to work independently.

Working experience Microsoft Access and Excel

“EPIC” Tapestry Experience

Other

Required: Ability to communicate readily and easily.

Excellent written and verbal communication skills.

Analytical and customer service orientations are essential.

Preferred: Ability to analyze data.

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

Kelsey-Seybold Clinic strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by organizational policy or by federal, state, or local laws unless such distinction is required by law. Kelsey-Seybold is a VEVRAA Federal Contractor and desires priority referrals of protected veterans.