Sr. Performance Improvement Analyst - Professional Support - FT - Days

Start the day excited to make a difference…end the day knowing you did. Come join our team.

Job Summary:

The Senior Analyst, Performance Improvement is responsible for the design, implementation, and performance of services to support ongoing and focused professional practice evaluation (peer review) for the medical staff and allied health professionals credentialed via the medical staff process. The Senior Analyst will educate medical and hospital staff on accreditation and other regulatory requirements relevant to professional review activities. This position will be responsible for working with medical staff leaders on the design of practitioner-specific performance feedback reports including providing guidance on the development of performance criteria. The Senior Analyst will work collaboratively with the MWH Centralized Credentialing Services to assure that performance data is integrated into the credentialing process. This position is responsible for assisting with the hiring, training, and managing of the Medical Staff Performance Improvement Analysts.

Essential Functions & Responsibilities:

• Collaborates with appropriate physician leaders and other departments involved in data collection to identify and implement medical staff performance measures.

• Designs and implements an information management system that supports management of practitioner-specific performance data including trend analysis and peer review conclusions, in collaboration with the Information Services Department

• Works in collaboration with the credentialing staff to establish processes, data collection methods, and documents to support integration of performance data into the following professional review activities: provisional/focused reviews for initial appointment and extension of privilege(s) and re-appointment review processes.

• Provides leadership for the design, implementation, generation, and dissemination of practitioner-specific performance feedback reports/profiles.

• Performs clinical reviews in accordance with defined procedures and/or directions of medical staff leaders in a timely manner forwarding cases for physician level review, performing follow-up, when appropriate referring issues related to operations to an appropriate leader, and entering data into the medical staff quality database.

• Provides support to the Chair, Physician Quality Management Committee including development of policies and procedures related to professional practice reviews, report preparation, and meeting coordination.

• Designs and implements methods to achieve compliance with accreditation, licensure, and regulatory requirements pertaining to peer review in collaboration with the Director and appropriate medical staff leader(s).

• Assists the Director with the budget preparation and department leadership relevant to the Performance Improvement Analyst's scope of responsibilities.

• Performs other duties as assigned.

Qualifications:

• Valid RN License from Virginia or reciprocal compact state

• Minimum of ten (10) years prior healthcare quality related work experience required (quality/utilization management, performance improvement, case management, risk management).

• Bachelor's Degree preferred and will be considered in lieu of minimum experience.

• Certified Professional Healthcare Quality (CPHQ) preferred.

• Prior work experience in the following disciplines preferred: medical staff quality/peer review, healthcare quality, performance improvement, risk management, and utilization/case management.

• Knowledge of Joint Commission and CMS standards pertaining to credentialing, ongoing and focused professional practice review (peer review), and performance improvement.

• Knowledge and work experience involving clinical data abstraction, data presentation, and statistics.

• Proficient in basic office information systems (Microsoft Office preferred), Internet skills, and data base management.

• Prefer prior experience with MIDAS or other quality/peer review information system.

• Requires strong organizational, time management, oral and written communication skills.

• Detail oriented with ability to interpret applicable regulatory requirements and apply knowledge to promote compliance.

• Recognize and maturely handle a variety of problems and situations, often of a confidential or urgent nature.

• Ability to preserve confidentiality despite pressure from physicians and outsiders.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.