Description
At NorthBay Health, the Patient Grievance Program Specialist is a clinical professional who works independently and collaboratively across all service lines (inpatient, outpatient, ambulatory, etc.) to coordinate, manage, and oversee the patient grievance process and support NorthBay Health to manage complaints and grievances. The Patient Grievance Program Specialist is responsible for managing, investigating, and resolving patient/member complaints, appeals and service recovery related to healthcare services, claims, and benefits, ensuring compliance with regulations (e.g., CMS, State DOH), documenting interactions, communicating resolutions, identifying trends for severity, frequency, and classification, identifying process improvement opportunities, and collaborating with clinicians and legal teams for fair, timely outcomes. The position serves as a subject matter expert for grievance processes, regulatory interpretation, and service recovery, partnering closely with clinical leaders, patient advocates, compliance, legal, and quality stakeholders.
The Patient Grievance Program Specialist reports to the Risk Management department within the Quality Division and functions in a highly regulatory-driven environment to support patient safety, transparency, and organizational risk mitigation. Key tasks include analyzing medical records, preparing documentation, liaising with members/providers, tracking cases in systems, and generating reports, requiring strong analytical, communication, and regulatory knowledge; recommending and implementing solutions and resolutions to risk-related issues and events; following up on the implementation and impact of proposed solutions and resolutions; having a general knowledge of organizational insurance programs and resources and collaborating with NorthBay Legal to manage claims against the organization's insurance program. Participate in multidisciplinary teams, standing work groups, councils and committees for the purpose of evaluating and improving patient care and patient experience. Support a culture of safety, transparency, and patient-centered care through consistent and professional grievance management.
This individual supports the Health System's objective of enhancing and promoting patient safety and quality of care.
Primary Job Duties
Intake & Investigation: Work independently in a highly regulated environment to receive, log, and investigate formal complaints (grievances) and appeals related to care, service, or access barriers. Lead and support service recovery efforts to address patient and family concerns in real time when possible, minimizing escalation to formal grievances.
Clinical Review: Review patient medical records, clinical documentation, and quality of care to understand the complaint's basis.
Resolution & Documentation: Determine root causes, develop resolution plans, and prepare accurate, concise written responses for patients and external parties.
Collaboration: Collaborative approach with multidisciplinary teams (ex. physicians, managers, legal, risk management, and other departments) to resolve complex cases. Utilizes and models TeamSTEPPS principles.
Regulatory Compliance: Ensure adherence to HIPAA, state (e.g., DHCS), and federal regulations for appeals and grievances.
Risk Management: Identifies organizational risk through trend analysis of incidents and reports and actively works on proactive risk mitigation.
Tracking & Reporting: Actively manages afterhours complaints and grievance. Track cases, identify trends, and prepare reports for management. Identify opportunities for systemic improvement based on service recovery trends and outcomes.
Patient Advocacy: Facilitates and manages the Patient Family Advisory Council (PFAC) program ensuring alignment with standards and requirements. Act as a liaison, communicating compassionately with patients and ensuring fair treatment.
Communication: Review, analyze and communicate all occurrence reports for Risk Management, quality of care, and regulatory concerns.
Professional Growth: Keeps abreast of all applicable regulatory requirements related to patient complaints and grievances. Develops or participates in the development of educational programs to raise staff awareness of risk exposure and the impact on professional liability, including Just Culture and High Reliability Organizations (HRO's).
Governance: Actively participates in committees directed toward promoting and improving quality of care.
Qualifications
Education: Bachelor's Degree required, in nursing or other healthcare related field. Master's Degree preferred.
Licensure/Certifications: California state registered nurse or allied health professional license preferred. CPHQ or CPPS on hire or within 24 months of hire.
Experience: Three to five (3-5) years of patient relations/grievance, risk management, service recovery, and/or patient experience highly preferred. Familiarity with CMS, Joint Commission, and state regulatory requirements. Experience supporting regulatory surveys or audits related to complaints and grievances. Knowledge and expertise of quality management/performance improvement methods, tools, and techniques (e.g., PDSA, Tests of Change, Six Sigma, LEAN) and ability to create and support an environment that meets the quality goals of the organization.
Job Skills: Excellent written and verbal communication skills, with the ability to draft regulatory-compliant grievance responses. Proven ability to conduct clinical chart reviews and synthesize complex information. Proficiency with Microsoft Office software. Strong knowledge and application of healthcare regulations related to patient complaints and grievances.
Interpersonal Skills: Demonstrates NorthBay's values and true north including nurturing care, own it, respect relationships, build trust, hardwire excellence Strong interpersonal skills. Ability to tackle complex situations involving physicians, patients and other personnel.
Hours of Work: Full time. Set by the department to meet NorthBay Health's needs. Work hours may vary based on work demands and reporting requirements. May require occasional travel between hospital, urgent care and ambulatory care sites.
Compensation: $61 to $93 per hour based on years of experience doing the duties of the role.
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