PATIENT EXPERIENCE COORDINATOR

Department: Clinic
Reports To:   Director of Quality 
Position Status: Full Time 
Location: Uintah Basin Healthcare / Uintah Basin Medical Center

POSITION SUMMARY

The Patient Experience Coordinator supports the Hospital's Quality, Patient Experience, and Regulatory Readiness programs. This position is responsible for coordinating the Hospital grievance process, maintaining accurate grievance and patient concern documentation, supporting the HCAHPS program, coordinating Quality-related meetings, maintaining quality and regulatory tracking tools, and assisting with audits and performance improvement activities.

The position serves as a key communication link between patients, families, providers, managers, and the Quality Department. The Coordinator ensures patient concerns and complaints are appropriately documented, communicated, investigated, tracked, and resolved in a timely manner.

The position supports compliance with CMS Conditions of Participation, DNV/NIAHO requirements, hospital policies, and applicable regulatory and accreditation standards.

ESSENTIAL FUNCTIONS

1. Patient Grievance & Complaint Management

• Serve as the primary coordinator for the hospital's patient grievance and complaint process.
• Receive, document, and track patient grievances, complaints, compliments, concerns, and service recovery opportunities.
• Maintain the hospital's Grievance Log and ensure information is complete, accurate, and current.
• Assign or communicate concerns to the appropriate department manager, provider, leader, or other responsible individual for review and follow-up.
• Track grievances from initial receipt through investigation, response, resolution, and closure.
• Follow up with departments and leaders to ensure timely completion of investigations and corrective actions.
• Prepare and send appropriate written responses to patients and/or representatives.
• Maintain documentation supporting grievance resolution and closure.
• Escalate unresolved, high-risk, regulatory, patient-safety, or potentially reportable concerns to the Director of Quality and appropriate leadership.
• Identify recurring concerns and trends and communicate findings to leadership and appropriate committees.
• Maintain confidentiality and protect patient information in accordance with HIPAA and hospital policy.
• Coordinate service recovery activities as directed.

2. HCAHPS & Patient Experience Program

• Coordinate the hospital's HCAHPS and patient experience program.
• Monitor HCAHPS results, trends, opportunities, and areas requiring improvement.
• Communicate patient experience concerns, compliments, and trends to department managers, providers, nursing leaders, and other appropriate personnel.
• Assist leaders in understanding patient feedback and identifying opportunities for improvement.
• Track patient experience concerns through resolution when follow-up is required.
• Assist with development and monitoring of patient experience improvement initiatives.
• Prepare patient experience information for leadership and Quality Committee review.
• Identify recurring themes in patient comments and complaints and communicate trends to appropriate leaders.
• Support patient experience education and awareness activities.

3. Patient Concern Tracking & Follow-Up

• Maintain an organized tracking system for patient concerns requiring follow-up.
• Monitor open concerns and ensure appropriate follow-up occurs.
• Communicate outstanding concerns to responsible managers and leaders.
• Document actions taken and outcomes.
• Close concerns when appropriate documentation and resolution have been completed.
• Identify concerns that may require Quality review, Risk Management involvement, financial review, and manager involvement.
• Maintain appropriate supporting documentation for survey readiness.

4. Quality Meeting Coordination

Quality Meetings

• Coordinate scheduling and preparation for designated Quality meetings.
• Surgical MAC, Medical MAC, Qualance, Quality Strategy
• Develop agendas in collaboration with the Director of Quality and appropriate leaders.
• Collect reports, data, and supporting documentation for meeting materials.
• Attend meetings and accurately document minutes.
• Maintain meeting minutes and supporting documentation.
• Track assigned action items and follow up with responsible individuals.
• Maintain documentation demonstrating completion of action items.

5. Quality Dashboard Management

• Maintain the hospital's Quality Dashboard as an active, accurate, and current management tool.
• Collect and enter monthly quality data.
• Ensure dashboard measures are updated according to established reporting schedules.
• Work with department leaders to obtain missing or delayed data.
• Monitor trends, significant changes, and areas requiring attention.
• Assist with preparation of monthly and quarterly quality reports.
• Maintain supporting documentation for reported measures.
• Assist the Director of Quality with identifying opportunities for performance improvement based on dashboard results.
• Ensure dashboard information is available for leadership, Quality Committee, and survey readiness activities.

6. Policy Stat Management

• Assist with administration and maintenance of the hospital's PolicyStat policy management system.
• Monitor policies approaching review or expiration dates.
• Communicate upcoming policy reviews to responsible departments and leaders.
• Assist with ensuring policies are accessible and current for staff and survey readiness.
• Support document control processes in accordance with hospital policy and regulatory requirements.

7. OneSource Management

• Assist with administration and maintenance of the hospital's OneSource document and resource management system.
• Maintain appropriate documents, resources, and reference materials.
• Assist departments with locating and maintaining current documents, IFUs, SDSs, and other applicable resources.
• Monitor assigned content for accuracy and availability.
• Assist with document control and survey readiness activities.
• Support department leaders in maintaining required documentation.

8. Quality Audits & Performance Improvement

• Assist the Director of Quality and department leaders with development and coordination of quality audits.
• Help create audit tools, spreadsheets, and tracking mechanisms.
• Schedule and coordinate audits as assigned.
• Collect and organize audit results.
• Enter and maintain audit data.
• Track identified opportunities for improvement.
• Assist with communicating audit findings to responsible departments.
• Track corrective actions and follow-up audits.
• Maintain audit documentation for Quality and regulatory readiness.

9. Quality & Regulatory Readiness

• Support the hospital's ongoing readiness for CMS, DNV/NIAHO, and other applicable regulatory and accreditation requirements.
• Maintain organized documentation demonstrating compliance with applicable requirements.
• Escalate identified compliance concerns to the Director of Quality.

10. Communication & Collaboration

• Maintain professional communication with patients, families, providers, nurses, managers, and hospital leaders.
• Communicate patient concerns in a professional, objective, and nonjudgmental manner.
• Maintain appropriate confidentiality.
• Establish effective working relationships with departments throughout the organization.
• Serve as a resource for managers regarding patient complaints, HCAHPS feedback, quality data, and follow-up expectations.
• Promote a culture of patient-centered care, accountability, service recovery, and continuous improvement.

REQUIRED KNOWLEDGE, SKILLS & ABILITIES

Knowledge

• Patient grievance and complaint management
• Patient experience principles
• HCAHPS processes and terminology
• Quality improvement principles
• Hospital regulatory and accreditation requirements
• CMS Conditions of Participation
• DNV/NIAHO standards
• Document control
• Basic quality measurement and auditing principles
• HIPAA and patient confidentiality requirements
• Microsoft Office/Google Workspace and electronic database systems

Skills

• Excellent written and verbal communication
• Strong organizational and time-management skills
• Accurate documentation and recordkeeping
• Meeting coordination and minute-taking
• Data entry and quality tracking
• Spreadsheet and dashboard management
• Professional patient communication
• Conflict resolution and service recovery
• Ability to prioritize multiple deadlines
• Ability to identify trends and communicate concerns appropriately

Abilities

• Work independently while maintaining appropriate communication with leadership.
• Maintain confidentiality and exercise sound judgment.
• Communicate effectively with individuals at all levels of the organization.
• Manage multiple projects and deadlines simultaneously.
• Follow established regulatory, organizational, and departmental requirements.
• Demonstrate attention to detail and accuracy.
• Recognize issues requiring escalation.
• Maintain professionalism when dealing with difficult or sensitive patient concerns.

MINIMUM QUALIFICATIONS

• High school diploma or equivalent required.
• Healthcare experience preferred.
• Experience in quality, patient experience, healthcare administration, medical records, customer service, or a related healthcare field preferred.
• Experience with electronic documentation systems, spreadsheets, and data tracking preferred.
• Experience with hospital quality, regulatory, accreditation, grievance, or patient experience processes preferred.

Preferred Qualifications:

• Associate in healthcare administration, nursing, business, quality, or related field.
• Experience with HCAHPS or patient experience programs.
• Experience with CMS, DNV/NIAHO, or other healthcare regulatory requirements.
• Experience with quality improvement and performance improvement activities.

PERFORMANCE EXPECTATIONS

The Quality & Patient Experience Coordinator is expected to:

1. Maintain an accurate and current grievance log.
2. Ensure patient grievances receive appropriate follow-up and written response within required timeframes.
3. Maintain accurate documentation supporting grievance resolution.
4. Keep the HCAHPS and patient experience tracking process current.
5. Ensure patient concerns and trends are communicated to appropriate leaders.
6. Maintain the Quality Dashboard according to established monthly reporting timelines.
7. Maintain accurate PolicyStat and OneSource documentation.
8. Coordinate assigned Quality, Quality MAC, and Surgical MAC meetings.
9. Maintain accurate meeting minutes and action-item tracking.
10. Assist with scheduled quality audits and follow-up.
11. Maintain organized documentation supporting CMS/DNV survey readiness.
12. Escalate significant patient safety, compliance, regulatory, or unresolved concerns appropriately.

KEY PERFORMANCE INDICATORS

Performance may be evaluated using the following measures:

• Grievances documented and tracked accurately
• Timeliness of grievance follow-up and written responses
• Percentage of grievance files closed appropriately
• Timeliness of HCAHPS reporting and follow-up
• Completion of monthly Quality Dashboard updates
• Timeliness of policy review tracking
• Accuracy of meeting minutes and action-item tracking
• Completion of assigned quality audits
• Timeliness of audit follow-up
• Regulatory and survey-readiness documentation
• Department and leadership satisfaction with Quality support
• Identification and communication of recurring patient concerns and quality trends

CORE RESPONSIBILITY

The Quality & Patient Experience Coordinator helps ensure that patient concerns are heard, documented, communicated, investigated, and resolved—and that the organization uses patient feedback and quality data to improve care.

This position supports the Quality Department by turning patient feedback, quality data, audits, policies, and committee activities into organized documentation, measurable follow-up, and continuous improvement.