Description

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.

Provides leadership and operational oversight for Medical Management support operations, Coordination of Benefits (COB), Regulatory Reporting, Enrollment Data Validation (EDV), and Quality Assurance activities supporting Medical Management, Appeals & Grievances, Provider Disputes, Enrollment, and related health plan operations. Directs day-to-day operations involving referral navigation, incomplete referral resolution, home health referrals, DME referrals, and other specialty referral workflows while ensuring compliance with CMS regulations, health plan requirements, accreditation standards, and internal operational policies.

Oversees COB operations responsible for validating and maintaining accurate member other insurance coverage information to support claims processing, authorization reviews, payment integrity, and coordination with external payers. Leads regulatory reporting, universe management, data validation, audit preparation, and reporting activities including the review, scrubbing, reconciliation, and submission of operational universes and regulatory data for Appeals & Grievances, Provider Disputes, Enrollment, Medical Management, and related operational areas.

Provides leadership and oversight for Quality Assurance functions supporting Appeals & Grievances, Enrollment, Provider Disputes, and Medical Management operations, including quality review processes, operational monitoring, trend analysis, and identification of compliance or workflow gaps. Oversees staff responsible for quality auditing, universe review, regulatory reporting validation, and operational accuracy monitoring to ensure compliance, data integrity, and timely reporting.

Partners collaboratively with operational and executive leadership to improve workflows, strengthen regulatory compliance, support audit readiness, streamline operational processes, and implement continuous improvement initiatives that enhance operational performance, timeliness, payment accuracy, provider and member experience, and overall organizational effectiveness.

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:

• Master's Degree
• 5+ years of overseeing Healthcare Enrollment, COB and regulatory compliance with knowledge of CMS regulations and compliance standards
• 5+ years of leadership experience in quality assurance improvement, or operational compliance within a managed care environment
• Solid knowledge of HMO, PPO, and POS plan types including Medicare and commercial health plans
• Proven excellent written and verbal communication skills with Strong organizational skills and ability to follow through with multiple projects

Preferred Qualifications:

• 5+ years of EPIC Experience
• 3+ years of working in or with Medical Management
• 3+ years of Healthcare and regulatory experience
• 1+ years of Quality Assurance experience
• Experience with CMS MARx system

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 $91,700 - $163,700 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.