RN, Medical Staff & Quality Peer Review Coordinator - Baroness Hospital - Full-Time

Job Summary:

The Coordinator, Peer Review will support the hospital's medical staff peer review function and quality improvement in compliance with DNV Standards, CMS Conditions of Participation and Medical Staff Bylaws. The Coordinator, Peer Review will support Medical Staff peer review. The coordinator will determine and qualify cases for peer review, perform first level screening, prepare case review documents, document peer review results, produce reports and update the peer review/quality database timely. This position will also support the President of the Medical Staff, Chief Medical Officer, Medical Staff and the organization through use of clinical expertise in review of concerns regarding quality of clinical care and provider conduct.

o Reports directly to the Medical Staff Quality and Peer Review Manager.

o Conducts medical record reviews for first level screening and/or clinical review, prepare case review documents, assigns, communicates and coordinate case reviews with committee physician members, process initial case reviewer findings, write letters of inquiry or case appropriate correspondence to providers, process responses and draft case review presentation.

o Works to assure the peer review and quality process is functional and works to improve the quality of care provided by the medical staff.

o Performs Focused Professional Practice Evaluation (FPPE) and develop associated reports.

o Prepares and distributes Ongoing Professional Practice evaluations every 6 months and at provider reappointment.

o Arranges and attends the Peer Review Committee and the Multidisciplinary Improvement Committee meetings, documenting the peer review results, and prepares committee agendas and minutes drafts.

o Develops and maintains professional relationships and meets with medical staff leaders, members and hospital staff when required.

o Enters peer review and quality improvement from other medical staff committees and departments into the centralized database.

o Maintains knowledge of Medical Staff Bylaws and all standards and regulations involving medical staff peer review.

o Conducts quality of care medical record reviews as requested and may independently interview staff and/or medical staff for clarification when required.

o Ensures confidentiality with patient and physician information, PHI, and demonstrates understanding of HIPAA.

o Participates, and may independently represent the Medical Affairs Department, in meetings to enhance teamwork and efficiency within internal and external departments.

Education:

Required:

Registered Nurse

Preferred:

N/A

Experience:

Required:

o Three to five years of recent healthcare experience in an acute care or critical access facility.

o Proficient in computer and internet skills, specifically MS Office Word, Excel, and PowerPoint.

Preferred:

o Previous experience with MS Visio, pivot tables, other information and data analysis tools.

o Experience with use of improvement science tools (e.g. PDCA/PDSA cycles, Key Driver Diagrams, Process Maps) desired, however department will train.

o Experience with facilitation in process improvement (PI) projects.

o Understanding of accreditation and regulatory requirements.

o Familiarity with ISO 9001: 2015 criteria.

o Experience with Electronic Medical Record chart review.

Position Requirement(s): License/Certification/Registration:

Required:

License to practice nursing in the State of Tennessee.

Preferred:

N/A

Department Position Summary:

1.Reports directly to the Medical Staff and Quality Peer Review Manager.

2.Conducts medical record reviews for first level screening and/or clinical review, prepare case review documents, assigns, communicates and coordinate case reviews with committee physician members, process initial case reviewer findings, write letters of inquiry or case appropriate correspondence to providers, process responses and draft case review presentation.

3.Works directly with the Medical Staff and Peer Review Manager to assure the peer review and quality process is functional and works to improve the quality of care provided by the medical staff.

4.Performs Focused Professional Practice Evaluation (FPPE) and develop associated reports.

5.Prepares and distributes Ongoing Professional Practice evaluations every 6 months and at provider reappointment.

6.Arranges and attends the Multidisciplinary Peer Review Committee, documenting the peer review results, and prepares committee agendas and minutes drafts.

7.Develops and maintains professional relationships and meets with medical staff leaders, members and hospital staff when required.

8.Enters peer review and quality improvement from other medical staff committees and departments into the centralized database.

9.Maintains knowledge of Medical Staff Bylaws and all standards and regulations involving medical staff peer review.

10. Conducts quality of care medical record reviews as requested and may independently interview staff and/or medical staff for clarification when required.

11. Ensures confidentiality with patient and physician information, PHI, and demonstrates understanding of HIPAA.

12. Participates, and may independently represent the Medical Affairs Department, in meetings to enhance teamwork and efficiency within internal and external departments.

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