Quality Assurance Analyst

Shift: Day 5×8-Hour (08:00 – 17:00)

Description:

Job Description & Responsibilities:
The Grievances & Appeals Specialist plays a critical role in supporting patients and families by investigating complaints, concerns, and feedback received by the organization. The responsibilities include:

Investigating patient/family complaints related to care quality, physician/provider actions, Sutter Health policies, and potential liability.
Handling highly complex and conflict-heavy cases, requiring innovation and collaboration across departments.
Working closely with managers, physicians, and staff to resolve patient grievances.
Coordinating with Legal and Risk Management on medical-legal matters.
Providing crisis intervention and mediation for complex institutional concerns.
Conducting case investigations, including interviews with patients/families, medical record reviews, and policy/procedure evaluations.
Facilitating case conferences and working with leadership to implement corrective action plans for quality improvement.
Ensuring compliance with CMS Conditions of Participation and Sutter Health grievance policies.
Maintaining a patient and family-centered approach, prioritizing transparency and resolution at the most appropriate levels.
Managing a high caseload and ensuring timely documentation to meet regulatory timelines.
Qualifications & Skills:
Education:
Bachelor’s degree in Business Administration, Nursing, Social Work, or another healthcare-related field, or equivalent education/experience.
Experience:
Minimum 2 years of recent relevant experience in grievances, appeals, or patient advocacy.
Skills Required:
Strong oral and written communication for composing patient responses and synthesizing investigation findings.
Analytical skills for medical record reviews, quality-of-care investigations, and patient safety concerns.
Case management expertise, handling high volumes while ensuring timely compliance.
Conflict resolution and problem-solving in a high-stakes, fast-paced healthcare environment.
Technical proficiency in word processing, email, database management, and patient care software.
Cultural competence and ability to navigate sensitive diversity-related concerns.
Autonomy and resourcefulness in handling complex grievance cases.