Grievances & Appeals Specialist

 

Organization:

MPHS-Mills-Peninsula Medical Center

Position Overview:

The Grievances & Appeals Specialist supports the patient and family experience through the investigation of patient/family complaints, concerns, and other feedback received by the organizations. Complaints and grievances include, but are not limited to, the care provided by physicians and other health care professionals, potential liability, quality of care, Sutter Health policy and procedure, and extensive conflict resolution with challenging patients and families.

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Problems encountered are often of a high level of complexity and require a great deal of innovation. Must collaborate closely with managers, physicians and staff throughout the organization. Collaboration across Legal and Risk Management Services is required on a frequent basis for complex medical legal issues. Assists staff members who request intervention in diffusing difficult or volatile patient situations.

Job Description:

These Principal Accountabilities, Requirements, and Qualifications are not exhaustive but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

Investigates patient complaints, and provide crisis intervention and mediation for complex situations throughout the institution. Performs case investigation which includes but is not limited to issue clarification through interviews with patients and families, medical record review, policy and procedure review, interviews with hospital staff and physicians, facilitates case conferences, and consultation with Risk Management, administration, and other involved departments. Partners with leadership to create action plans around patient complaint investigation/reviews and related quality improvement.

Strives to achieve resolution of complaint/problem at the most appropriate level within the organization structure which requires significant interaction at staff, supervisory, department head, and clinical/administrative levels. Maintains a Patient & Family-Centered approach working in partnership with patients and families on an individual and system level when reviewing concerns, complaints, and/or feedback to improve our organization.

With assistance from the leader(s) of Patient Relations and Patient and Family Experience, initiates corrective action as appropriate.

Complies with Center for Medicare & Medicaid Services (CMS) Condition of Participation and Sutter Health policies regarding responding to patient/family concerns, complaints, and grievances. Communicates action to patients, families, and staff who are involved or will be affected by the results of the investigation.

EDUCATION:
Equivalent experience will be accepted in lieu of the required degree or diploma.

Bachelor's: degree in Business Administration, Nursing, Social Work, or other healthcare-related field or equivalent education/experience

TYPICAL EXPERIENCE:

2 years of recent relevant experience

SKILLS AND KNOWLEDGE:

Oral and written communication skills. must demonstrate writing skills including the ability to synthesize the facts of an investigation and respond with compassion to patients on behalf of the organization.

Analytical skills, including medical record review/analysis, investigation of quality of care complaints, and synthesizing facts to follow up on related patient complaints and related safety issues.

Case management skills: the ability to manage a high caseload while providing documents and timely responses to meet regulatory timelines.

Must possess interpersonal, conflict resolution, and problem-solving skills while working in a fast-paced environment.

Computer skills including word processing, email, calendar and database, and departmental-specific software.

Sensitivity to issues of diversity and demonstrates cultural competence.

Ability to work collaboratively with managers, faculty, and staff throughout the institution.

Ability to work independently and be resourceful when navigating complex situations.

PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements

Pay Range : $35.99 - $53.99

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

None

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $35.99 to $53.99 / hour. Pay Range Pay Range is $35.99 to $53.99 / hour.

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

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