Peer Review and Grievances RN Full Time at Pipeline Health · Gardena

Job Summary:

The Peer Review & Grievances RN supports the Director Quality & Performance Excellence by coordinating clinical case review, physician peer review workflow, mortality and high-risk case screening, and hospital grievance management across Memorial Hospital of Gardena and Coast Plaza Hospital. The position ensures that cases are identified, organized, tracked and routed through the appropriate medical staff and hospital governance processes while maintaining confidentiality, timeliness, documentation integrity and clear follow-through on identified actions.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions:

• Screen assigned mortality, high-risk, adverse outcome, readmission, transfer, clinical deterioration and other cases for potential quality-of-care concerns using established review criteria.
• Prepare concise, objective clinical case summaries, timelines and supporting documentation for physician review and medical staff peer review activities.
• Coordinate case assignment to appropriate physician reviewers and track review completion, follow-up questions, committee disposition and assigned actions.
• Maintain peer review tracking systems, case status logs, due dates and documentation in accordance with approved processes and confidentiality requirements.
• Support the Director and Medical Staff leadership with recurring trend identification, practitioner-specific quality concerns, service-line patterns and opportunities that may warrant focused review or performance improvement.
• Support OPPE/FPPE-related case identification and data preparation when requested by Medical Staff leadership or the Director, consistent with established medical staff processes.
• Coordinate the hospital grievance process, including receipt, triage, investigation support, department follow-up, response drafting, tracking and closure.
• Ensure grievance reviews include appropriate clinical, operational and communication perspectives and are escalated when significant quality, safety, regulatory or physician-related concerns are identified.
• Track grievance themes and provide trend reports to the Director, Quality & Risk Manager, Patient Experience and relevant committees.
• Refer recurring system issues from grievance and peer review activity to the Quality Improvement & Patient Experience RN for structured improvement work.
• Support regulatory, accreditation and complaint-survey requests involving grievance or peer review process evidence as directed by the Director.
• Participate in selected RCA, case conferences, mortality review, quality committees and physician-related investigations as assigned.
• Maintain strict confidentiality of protected peer review, patient and practitioner information and use secure processes for case handling and communication.
• Communicate overdue reviews, unresolved clinical concerns and barriers to timely case closure to the Director.

Grievance Management Responsibilities:

• Maintain a centralized grievance log for both hospitals with date received, issue category, responsible department, investigation status, response due date, closure date and identified trends.
• Coordinate fact-finding with nursing, physicians, ancillary departments, Risk Management, Patient Experience and other stakeholders as appropriate.
• Draft clear, professional grievance responses for leadership approval without disclosing protected peer review information.
• Differentiate individual service recovery opportunities from recurring system issues requiring formal improvement or leadership escalation.
• Monitor timeliness and escalate cases at risk of missing organizational or regulatory response expectations.

Peer Review Responsibilities:

• Maintain objective case chronology and supporting documentation.
• Facilitate review workflows through initial screening, physician review, committee consideration, action tracking and closure.
• Track cases requiring additional information, second-level review, focused evaluation or medical staff follow-up.
• Prepare de-identified or appropriately limited trend summaries for quality governance as directed.
• Support documentation of committee recommendations and ensure assigned follow-up is tracked to completion.

Behavioral Standards:

• Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude.
• Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.

Communication/Knowledge:

• Clinical Record Review: Demonstrated ability to thoroughly review and evaluate complex clinical records, EHR systems, and medical documentation for accuracy and compliance.
• Objective Case Analysis & Chronology Development: Advanced proficiency in conducting objective case evaluations and synthesizing complex medical files into detailed timelines and chronological summaries.
• Professional Writing: Superior professional writing skills with a proven track record of authoring clear, structured, and defensible reports for executive, clinical, and legal audiences.
• Confidentiality & Discretion: Deep knowledge of HIPAA regulations, privacy laws, and best practices for managing sensitive Protected Health Information (PHI) with utmost discretion.
• Physician Communication: Strong interpersonal and verbal communication skills required to effectively engage, consult, and interface with physicians and medical specialists.
• Organization & Deadline Management: Exceptional organizational skills with the ability to manage competing priorities, track multiple case files, and consistently meet strict deadlines.
• Trend Identification: Strong analytical skills to identify systemic patterns, recurring clinical variances, and emerging risk trends across case data.
• Escalation Judgment: Sound professional judgment and critical thinking skills to recognize high-risk issues and determine appropriate pathways for timely escalation.
• Collaboration Across Departments: Proven ability to build collaborative working relationships across cross-functional teams, including risk management, legal, quality, and clinical departments.
• Available to participate in on-call rotations and respond to department needs as required.
• Provides on-call support as needed to meet operational and departmental demands.
• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.

Collaboration/Teamwork:

• Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program

Qualification/Experience:

Minimum Qualifications

• Minimum three (3) years of acute-care clinical nursing experience preferred, with demonstrated ability to interpret complex medical records and clinical decision-making.
• Experience in quality, peer review, risk management, utilization review, case management, patient safety or grievance management strongly preferred.
• Strong writing skills and ability to produce concise, objective clinical summaries.
• Ability to work effectively with physicians, medical staff leadership, nursing leaders, patients/families, and executive leadership.
• High degree of discretion, professionalism, and confidentiality.

Preferred Qualifications

• Experience with medical staff peer review, OPPE/FPPE, mortality review and grievance workflows.
• Working knowledge of CMS, Joint Commission and California hospital grievance and quality requirements.