Patient Grievance Program Specialist

Overview

At North Bay 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 North Bay 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.

• 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 (e.g., 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:
  
  Identify organizational risk through trend analysis of incidents and reports and actively work on proactive risk mitigation.
• Tracking & Reporting:
  Actively manages after hours 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 (HROs).
• Governance:
  Actively participates in committees directed toward promoting and improving quality of care.

• 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…