Appeals Grievances & Dispute Analyst Team Lead - Kelsey-Seybold Clinic - Pearland

Improve the lives of others while Caring. Connecting. Growing together.

Appeals Grievances & Dispute Analyst Team Lead
- Kelsey-Seybold Clinic
- Pearland - 2381036

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.

• 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 time frames, 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

• 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…