Clinical Experience & Grievances Specialist

Job description

JOB SUMMARY This paragraph summarizes the general nature, level and purpose of the job. Responsible for reviewing clinical cases, complaints and grievances to meet and ensure regulatory compliance. This position will specifically be asked to focus on cases where clinical concerns/issues arise that need review to triage to and work alongside the appropriate clinical teams. Responsible for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records. Reviews clinical progress notes and determines if standards (high level) were met and/or who the appropriate medical leaders are to be pulled into the review. Collaborates with medical management staff in responding to grievance cases. Functions as a resource and a liaison between the patient, the medical center, and the community it serves; ensure patient rights are respected; and provide a channel for problem mediation and resolution to promote the highest quality of care and customer satisfaction. Supports the family and patient's care by providing non-medical guidance and assistance for the patient and family in assigned areas/tasks. To act as a communication liaison and to hear and understand the patient's individual needs, desires, and concerns, and then to guide and connect the patient and family to a range of non-medical services, amenities, and information that can support effective healing and ensure satisfaction with the hospital experience at Lucile Packard Children's Hospital. ESSENTIAL FUNCTIONS The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings. Must perform all duties and responsibilities in accordance with the hospital's policies and procedures, including its Service Standards and its Code of Conduct. *Manages complaints, grievances and feedback from patients and families with a focus on those of clinical nature and regarding APPs, abiding by all CMS and regulatory requirements. *Conducts clinically based concurrent and retrospective chart reviews of both inpatient and outpatient medical records. *Meets regularly with medical management staff in clarifying and resolving clinical grievance and appeal cases. *Assesses current state/need and identifies the correct clinical team members and seek their feedback to respond to patient grievances. Conducts analysis of information gathered and formulates conclusions. Identifies patient safety/risk management concerns and follow standard workflows to escalate accordingly. Writes responses to complex formal grievances, including multiple perspectives, upholding regulatory requirements, ensuring limited risk and upholding our mission of compassionate care. *Works alongside and assists the Physician Experience Program Manager to review and ensure timely response for medical staff grievances. *Collaborates with Patient Relations and Physician Leaders, Risk, PI, Quality/Safety and Regulatory Affairs related to grievance processing that ensures the most positive outcome possible maximizing patient satisfaction, minimizing liability risks while complying with internal and external regulations. Supports Patient Rights & Responsibilities and role models excellent customer services and interpersonal communication. *Acts as key interface with physician staff, hospital/clinical directors and patient representative to maintain regular communication and documentation among team during the investigation. *Develops written responses from comprehensive multidisciplinary reviews following established complaint handling pathway, to ensure all concerns are given impartial consideration and that appropriate responses occur in keeping with regulatory and hospital guidelines; obtain approvals and signatures and ensure responses are mailed to complainant. *Reviews all appropriate documents (letters, reports); analyzes detailed clinical documentation. *Updates complaint resolutions in the PR database which is used for quality improvement activities for the organization. *Cover phone line, welcome calls, patient/family rounding as assigned. *Collaborates with team members to develop improvement projects to address patient feedback. Assists with identifying areas for improvement based on daily interactions with patients and observations. Works with unit personnel on initiatives to improve the patient experience. *Provides support and guidance during patient hospital stay or clinic visit and being responsive to any concerns or complaints the patient and/or family may have. Provides resolution of issues at point of service. Acts as non-clinical liaison/concierge/navigator for patient in all aspects of their care at SMCH before, during or after an encounter with a SMCH site. Serves as a link to services across the health system: social work, pastoral care, physical therapy, other specialties; connecting patients to financial counseling or other care settings. MINIMUM QUALIFICATIONS Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying. Education: Bachelor’s degree in a work-related discipline/field from an accredited college or university. Experience: 3 years of progressively responsible directly related work. License/Certification: Registered Nurse (RN) KNOWLEDGE, SKILLS, & ABILITIES These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education or licensure/certification. *Clinical background and knowledge of medical terminology and complex/matrixed healthcare environments. *Ability to comprehend and discuss patients' medical care and nursing care with medical staff, advanced practice providers, nurses and other healthcare professionals in order to assess patient grievances. *Ability to efficiently review and synthesize information in a patient’s medical record. *Ability to be diplomatic and highly organized. *Ability to comprehend and discuss patient's medical care and nursing care with physicians, nurses and other healthcare professionals in order to assess patient grievances. *Ability to communicate effectively, both orally and in writing. *Ability to display a highly professional demeanor and customer service skills. *Ability to establish and maintain effective relationships with widely diverse groups, including individuals at all levels both within and outside the organization and gain their cooperation. *Ability to handle potentially sensitive situations by applying consultative skills in working with internal and external constituent groups. *Ability to understand and develop in-depth knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare/Medicaid regulations. *Ability to remain calm under pressure and apply sound judgment. *Ability to resolve conflicts and/or negotiate with others to achieve positive results; establish and maintain effective interpersonal relationships. PHYSICAL REQUIREMENTS The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job. Pay Range Compensation is based on the level and requirements of the role. Salary within our ranges may also be determined by your education, experience, knowledge, skills, location, and abilities, as required by the role, as well as internal equity and alignment with market data. Typically, new team members join at the minimum to mid salary range. Minimum to Midpoint Range (Hourly): $76.28 to $95.67 Stanford Medicine Children's Health (SMCH) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SMCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance. At Lucile Packard Children’s Hospital Stanford, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time. Job ID: LP_00018319-2653387