Complaint Research Specialist

Summary

Build your Career. Make a Difference. Presbyterian is hiring a skilled Complaint Research Specialist to join our team.

Responsibilities

• Respond to verbal and written complaints, grievances, and requests for appeals involving complex matters.
• Perform comprehensive research to clarify facts and circumstances.
• Identify the root cause for an issue.
• Absorb exceptional service when acknowledging, discussing, documenting, or responding to patients' or their representatives' dissatisfaction.
• Makes initial decisions regarding complaints, grievances, or appeals based on completed research.
• Ensure issues are categorized and can be reported to internal stakeholders, oversight committees, and regulatory agencies.
• Act as a patient advocate in each case, comparing the grievant/appellant's issues with the organization's documented facts.
• Document the substance of each complaint, grievance, or appeal case both electronically and in hard file according to legal requirements.
• Communicate in writing with customers, members, providers, or designated representatives; using the regulatory compliant format on all issues both for acknowledgment and resolution.
• Review research performed by other referral sources, department heads, other departments, and conduct more detailed investigative research into the matter to resolve issues of complaint, grievance, or appeal.
• Make decisions in cases of dispute that were not decided or resolved by other referral sources.
• Apply contract language from both member contracts and employer contracts in researching and deciding outcomes.
• Work closely with Legal/Risk Management, Medical Staff, Medical Directors, Department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, grievances, and appeals.
• Present completed research file along with initial recommendation for resolution to appropriate Complaint Management Coordinator for review and final approval within the time period necessary to remain in compliance with regulatory requirements for appeals, grievances, or complaints.
• File and document preparation of all cases that proceed to further internal or external review and for regulatory and oversight audit activities.
• Communicate complaint resolutions/decisions to grievant, legal representatives, and providers both telephonically and in writing.
• Log complaints, grievances, and appeals issues, and identify trends.
• Document or phone log all issues processed and categorize accordingly.
• Maintain the effectiveness of resolutions/outcomes as a result of the complaint/grievance/appeal process.
• Assist in the development of process improvement functions that result from complaints, appeals, and grievance processing.
• Identify errors and inconsistencies that require revisions to guidelines or system modifications, bringing errors to the attention of appropriate personnel in each affected department or quality committee responsible for addressing such processes.
• Identify and refer issues to other key processes such as risk management, billing audits, or legal.

Qualifications

• High School education or G.E.D. equivalent required.
• Associates Degree preferred.
• Three years experience in a customer service setting required, with one year in a health care environment preferred.
• Experience in managed care field such as Claims or Member Services strongly preferred.
• Experience with healthcare databases is preferred.

Benefits

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits. Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinars, preventive screenings, and more.

About Presbyterian

About Presbyterian Healthcare Services: Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Why Work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.