[Hiring] Appeals and Grievances Quality Analyst @UnitedHealth Group

Role Description

This position leads quality reviews for the KelseyCare Advantage Operations Department, including Appeals & Grievances, Enrollment, Premium Billing, Eligibility, Intake, and Regulatory Teams. It addresses system issues, troubleshoots problems, and collaborates with IT and management to resolve them. The role supports process improvements and ensures effective use of health plan information and CMS guidelines.

• Analyze eligibility data
• Review CMS transaction reports
• Load weekly files
• Identify errors and optimize workflows
• Monitor appeals and grievances for timeliness and accuracy
• Ensure documentation consistency
• Train new Appeals & Grievances Coordinators
• Handle complex cases, including multiple complaints, missed grievances, and appeals submitted to CMS
• Create, analyze, and submit reports for CMS audits and compliance monitoring
• Identify trends in appeals and grievances
• Support training development
• Coordinate system updates
• Collaborate with the Operations Trainer on documentation
• Present cases during CMS audits and recommend process improvements

Qualifications

• High School diploma or equivalent
• 3+ years of experience with Healthcare Appeals and Grievances
• 2+ years of Medicare Advantage experience
• Knowledge of CMS Regulations including Appeals and Grievances, Enrollment, and Member Services
• Knowledge of CMS regulations
• Knowledge and ability to Interpret/Apply CMS Coverage Rules regarding Appeals
• Knowledge of Appeals and Grievances reporting and audit requirements
• Demonstrated analytical skills including file format manipulation and data comparison

Requirements

• Epic Managed Care experience (preferred)
• Experience in Health Plan Operations in Healthcare Industry (preferred)
• Knowledge of CMS Audits (preferred)
• Proven ability to analyze and report on appeals and grievance trends and quality error rates (preferred)

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (subject to eligibility requirements)
• Hourly pay range: $20.38 to $36.44 per hour based on full-time employment

Company Description

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. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes.

• OptumCare is an Equal Employment Opportunity employer
• Candidates will receive consideration for employment without regard to protected characteristics
• OptumCare is a drug-free workplace