Complaints & Grievance Specialist

Job Description

Job Description

The Complaints and Grievance Specialist play a crucial role in ensuring patient satisfaction, quality of care, and compliance with regulatory requirements ensuring the timely resolution of complaints and grievances received by conducting investigations, maintaining records, and reporting to the impacted personnel and entities the resolution and status of complaints and grievance received. Also, is responsible of ensure compliance with healthcare regulations, laws, business partners contracts and accreditations requirements. As part of the investigation, the Complaint and Grievance Specialist shall identify opportunities of improvement of operational processes and systems to promote patient satisfaction and quality of care provided by Alivia Health employees.

Responsibilities:

• Receive and document complaints and grievances received through various channels, such as phone calls, emails, and written correspondence.
• Conduct thorough investigations into complaints and grievance, gathering relevant information from patients, providers, staff, and medical records to understand the issue and identify root causes.
• Maintain detailed records of complaints and grievance cases, including all communications, actions taken, and resolutions achieved to accurately report the status to the impacted personnel and entities in a timely manner. 
• Work with multidisciplinary teams to develop and implement appropriate solutions to resolve complaints and grievance and prevent recurrence.
• Effectively communicate with patients, healthcare providers and business partners to provide updates and gather additional information as needed.
• Ensure compliance with all applicable laws and regulations, including but not limited to HIPAA and CMS guidelines, and internal policies.
• Prepare regular reports on complaint and grievance trends, including recommendations for process improvement.
• Analyze complaint and grievance data to identify trends and areas of opportunities for improvement of process and system issues that contribute with the receipt of complaints and grievances.
• Provide training and education to impacted personnel to prevent and correct the issues identified during the investigation of complaint and grievance. 
• Participate in staff training programs related to complaint and grievance management.
• Support the Quality & Compliance Staff in preparation and participation of meetings with operational management. 

Required:

• Minimum of two (2) years of pharmacy or related field experience in health or health care industry experience; two (2) years of experience in conducting monitoring/audits, and/or data analysis.
• Knowledge of healthcare regulations and compliance.
• Previous experience as a compliance analyst in a related field, preferred.
• Knowledge of pharmacy industry or managed care compliance requirements and standards, preferred.