Senior Quality Analyst - Clinical Quality Investigation

Overview

Description The Case Manager, Clinical Quality Investigations, is an expert consultant, investigator, case manager and delegate of Swedish Medical Center's Board for hospital and hospital-based outpatient clinical care grievances. This person operates in a high-volume, high-stress environment and has multi-campus responsibility to ensure that clinical care grievances are responded to and documented in compliance with Swedish Medical Center policy and in accordance with requirements of external regulatory agencies, including The Joint Commission, Det Norske Veritas, The Center for Medicare/Medicaid Services, and the Washington State Department of Health.

The Case Manager is the primary intake for regulatory and business complaints and grievances concerning clinical quality of care, such as from the Medical and Nursing Quality Commissions, Better Business Bureau, Office of Civil Rights, and Medicare Quality Improvement Organization Program (contracted to Kepro as of 10/29/2019). When external regulatory agencies request a patient s medical record from Swedish Medical Center, it will be the responsibility of the Case Manager to perform a preliminary review of the record to identify any potential deficiencies in care, with the results reported to the Accreditation department.

This role affects system change through analysis and reporting of common causes of clinical care grievances, advising clinical leaders of patterns and opportunities for improvement. Additionally, this person provides education to and directs all levels of the organization regarding appropriate and effective management of clinical care grievances. Acts as a resource to evaluate the standard of care and complex clinical concerns that have been initiated by the patient or their advocate.

The Case Manager uses clinical expertise and effective analytic and communication skills to investigate, interpret and clearly communicate to the patient complex clinical and other findings. Interfaces with Risk Management to assess situations for hospital liability and develop appropriate responses, including recommending goodwill adjustments of patient bills. Interfaces with the Accreditation Department for concerns triggering non-compliance with regulatory standards, and with the Quality Department for needs related to root cause analysis and patient safety.

This person works directly with a multicultural and socio-economically diverse patient population and with individuals who frequently demonstrate distress, threatening behavior and anger, collaborating with Security and law enforcement agencies as necessary to ensure safety of self, colleagues, patients, and visitors.

• Serve as the primary intake point for regulatory and business complaints and grievances related to clinical quality of care.
• Ensure grievances are responded to and documented in compliance with Swedish Medical Center policy and external regulatory requirements.
• Conduct preliminary reviews of medical records requested by external regulatory agencies to identify potential deficiencies in care and report findings to relevant departments.
• Analyze causes of clinical care grievances and advise clinical leaders on patterns and opportunities for improvement to drive system change.
• Educate and direct all levels of the organization on appropriate and effective management of clinical care grievances.
• Evaluate standards of care and complex clinical concerns initiated by patients or their advocates.
• Investigate and communicate complex clinical findings clearly to patients and stakeholders using clinical expertise and strong analytic/communication skills.
• Interface with Risk Management to assess hospital liability and develop appropriate responses, including recommending goodwill adjustments of patient bills.
• Coordinate with the Accreditation Department on concerns triggering non-compliance and with the Quality Department on needs related to root cause analysis and patient safety.
• Collaborate with Security and law enforcement as necessary to ensure safety of staff, patients and visitors in a multicultural and diverse environment.

• Required:
  
  5 years as a clinician in a healthcare setting with at least two years in management, education, or related to clinical quality; or a graduate degree and at least 10 years of experience in a quality investigation position in lieu of clinical education.
• Experience working with individuals in distress and developing quality improvement initiatives in healthcare.
• Experience in investigation, including review of medical documents and interpersonal interactions.
• Experience in managing upward and achieving desired results.
• Effective verbal communication skills in large group and one-to-one settings.
• Documented ability to compose clear written communications with grammatical accuracy and professional tone.

• Bachelor s Degree in Nursing or equivalent education/experience.
• Bachelors or Masters Degree in related field with relevant…