Complaint Research Specialist

Location: 9521 San Mateo NE, Albuquerque, NM 87113-2237

About the Role

Presbyterian is hiring a skilled Complaint Research Specialist to join our team. This is a full-time, non-exempt position based at the Reverend Hugh Cooper Administrative Center with a day shift schedule.

Pay

Compensation range: $19.25 – $31.74 per hour.

Responsibilities

• Respond to verbal and written complaints, grievances, and requests for appeals involving complex matters.
• Perform comprehensive research to clarify facts and circumstances, identifying root causes of issues.
• Ensure patients and/or their representatives receive exceptional service when acknowledging, discussing, documenting, or responding to dissatisfaction.
• Make initial decisions regarding resolution of complaints, grievances, or appeals based on completed research.
• Categorize issues for reporting to internal stakeholders, oversight committees, and regulatory agencies.
• Act as a patient advocate by comparing the grievant/appellant's issues with the organization's documented facts.
• Gather necessary documents (internal and external) to develop complete files for appeals, grievances, or complaints.
• Collect information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and subject matter experts.
• Use documentation such as DART, provider manuals, member contracts, and online policies to support accurate decisions on claims payment, authorizations, contractual issues, and care standards.
• Document each case electronically and in hard files according to legal requirements.
• Make direct verbal contact with customers during the research process to fully document issues.
• Communicate in writing with customers, members, providers, or designated representatives using regulatory-compliant formats for acknowledgment and resolution.
• Review research performed by other referral sources or departments and conduct further investigative research to resolve issues.
• Make decisions in disputed cases unresolved by other sources, using policy guidelines, detailed research, and a standard of reasonableness.
• Apply contract language from member and employer contracts in researching and deciding outcomes.
• Collaborate with Legal/Risk Management, Medical Staff, Medical Directors, Department Directors, regulatory representatives, and outside consultants to achieve consistent outcomes.
• Present completed research files with initial recommendations for resolution to the Complaint Management Coordinator for final approval within regulatory timeframes.
• Prepare files and documentation for further internal or external review and regulatory audits.
• Communicate resolutions/decisions to grievants, legal representatives, and providers both telephonically and in writing.
• Understand and apply regulatory requirements for complaint, grievance, and appeals processing.
• Log complaints, grievances, and appeals, identifying trends and ensuring proficient database entry and categorization.
• Document or phone log all processed issues and categorize them accordingly.
• Monitor the effectiveness of resolutions/outcomes from the complaint/grievance/appeal process.
• Assist in developing process improvements resulting from complaints, appeals, and grievance processing.
• Identify errors and inconsistencies requiring revisions to guidelines or system modifications, escalating them to appropriate personnel or committees.
• Refer issues to other key processes such as risk management, billing audits, or legal.

Qualifications

• High School education or G.E.D. equivalent required; Associate’s Degree preferred.
• Three years of experience in a customer service setting required, with at least one year in a healthcare environment preferred.
• Experience in the managed care field (e.g., Claims or Member Services) strongly preferred.
• Experience with healthcare databases is preferred.

Benefits

• Comprehensive benefits package including medical, dental, vision, short-term and long-term disability, and group term life insurance.
• Optional voluntary benefits.
• Employee Wellness rewards program offering gift cards and incentives for participating in wellness activities, challenges, webinars, and preventive screenings.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system comprising 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 over 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide, offering Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans. We are committed to improving community health through initiatives like hosting growers' markets and partnering with local communities.