Complaint Research Specialist

Location Address: 9521 San Mateo NE
Albuquerque, NM 87113-2237
 Compensation Pay Range: Minimum Offer $19.25
Maximum Offer $31.74
Now Hiring: Complaint Research Specialist Summary: Build your Career. Make a Difference. Presbyterian is hiring a skilled Complaint Research Specialist to join our team.

Type of Opportunity: Full time
Job Exempt: No
Job is based: Reverend Hugh Cooper Administrative Center
Work Shift: Days (United States of America)
 Responsibilities: Responsible for responding to verbal and written complaints, grievances, and requests for appeals that involve complex matters. Responsible for performing comprehensive research to clarify facts and circumstances. Able to identify the root cause for an issue. Assure that patients and/or their representatives receive exceptional service when acknowledging, discussing, documenting or responding to their issue of dissatisfaction.  Makes initial decision regarding resolution of complaints, grievances or appeals based on completed research.  Responsible for making sure that issues are categorized and can be reported to internal stakeholders, oversight committees and regulatory agencies.  Able to act as a patient advocate in each case, comparing the grievant/appellant's issues with the organization's documented facts. Some key responsibilities include Perform research related to the facts and circumstances of a complaint, a member appeal, or a customer grievance. Gathers necessary documents (from internal and external resources) related to an appeal, grievance or complaint to develop a complete file. Gathers information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and from subject matter experts in order to research the facts of all complaints, grievances and appeals. Uses available documentation including DART, provider manuals, member contracts and online policies and procedures to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the organization. Required to document the substance of each complaint, grievance or appeal case both electronically and in hard file according to legal requirements. Responsible for making direct verbal contact with customer who has filed a complaint, grievance or appeal during research process in order to fully document the issue. Required to communicate in writing with customers, members, providers or designated representative; using the regulatory compliant format on all issues both for acknowledgment and resolution. All written correspondence must be reviewed for regulatory statutes and requirements for all customer types. Must be able to professionally articulate orally and in writing an understanding of complex issues and detailed action plans. Responsible for reviewing 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. Responsible for making decisions in cases of dispute that were not decided or resolved by other referral sources. Such decisions will be made using policy and guidelines, detailed research and applying a standard of reasonableness, considering all actions previously taken by others. Responsible for application of contract language from both member contracts and employer contracts in researching and deciding outcomes. Works 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. Presents 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