(PC) 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 full-time, non-exempt position is based at the Reverend Hugh Cooper Administrative Center.

Responsibilities

• Respond to verbal and written complaints, grievances, and requests for appeals involving complex matters.
• Perform comprehensive research to clarify facts and circumstances, identifying the root cause of issues.
• Ensure patients and/or their representatives receive exceptional service when addressing 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, comparing the grievant/appellant's issues with documented facts.
• Perform research related to complaints, member appeals, or customer grievances, gathering necessary documents from internal and external resources.
• Gather information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and subject matter experts.
• Use documentation including DART, provider manuals, member contracts, and online policies to support decisions on claims payment, authorizations, and care standards.
• Document the substance of each case electronically and in hard files according to legal requirements.
• Make direct verbal contact with customers to fully document issues during the research process.
• Communicate in writing with customers, members, providers, or designated representatives using regulatory-compliant formats.
• Review research performed by other referral sources and conduct detailed investigative research to resolve issues.
• Make decisions in cases of dispute unresolved by other referral sources, using policy guidelines and detailed research.
• 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.
• Present completed research files with initial recommendations for resolution to the Complaint Management Coordinator for final approval.
• Prepare files and documentation for further internal or external review and regulatory audits.
• Communicate complaint 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 categorizing issues in databases.
• Document or phone log all processed issues and monitor the effectiveness of resolutions.
• Assist in developing process improvements resulting from complaints, appeals, and grievance processing.
• Identify errors and inconsistencies requiring revisions to guidelines or system modifications, referring issues to appropriate personnel.
• 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 Degree preferred.
• Three years of experience in a customer service setting required; 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.

Pay

Pay Range: $19.25 – $31.74 per hour.

Benefits

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes:

• Medical, dental, and vision insurance.
• Short-term and long-term disability.
• Group term life insurance and other optional voluntary benefits.

Wellness: Presbyterian's Employee Wellness rewards program offers opportunities to enhance health and activate well-being, including wellness challenges, webinars, preventive screenings, and earning gift cards.

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 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 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.

Schedule

Full-time, day shift (United States).