MANAGER OF PEER REVIEW

Cook County•Chicago, IL

6d•Onsite

About The Position

The Manager of Peer is responsible for the coordination, administration, and operational oversight of Cook County Health’s (CCH) peer review and physician quality review programs in support of patient safety, quality improvement, regulatory compliance, and physician accountability initiatives. The Manager ensures peer review activities are operationally supported, data-driven, and aligned with CCH policies, accreditation standards, regulatory requirements, and medical staff bylaws. The role serves as a liaison among operational, clinical, and physician leadership teams and leads initiatives to enhance the effectiveness, consistency, and integrity of peer review processes, reporting, and performance improvement efforts across the organization.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Quality, Public Health or related field is required (must provide official transcripts at time of interview)
Three (3) years of experience in healthcare quality, physician peer review, clinical operations, nursing leadership, risk management, and/or medical staff services is required
Experience with physician peer review processes, healthcare operations, accreditation standards, and/or quality improvement methodologies is required
Clinical background or experience collaborating with physicians and interdisciplinary clinical teams to support peer review, quality improvement, patient safety, and performance improvement initiatives is required
Knowledge of Joint Commission, CMS and healthcare regulatory standards
Commitment to patient safety, quality improvement and physician accountability
Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Demonstrate analytical and organizational, problem-solving, decision-making, critical thinking, and conflict management/resolution skills
Excellent program development, management, and leadership skills
Strong project management skills
Exceptional organizational skills and the ability to prioritize, plan, and organize projects and tasks
Ability to manage sensitive and confidential information appropriately
Ability to perform detailed chart abstraction and operational workflow analysis
Ability to prioritize and manage multiple concurrent reviews and deadlines
Ability to facilitate multidisciplinary collaboration and discussions
Ability to work collaboratively with physicians, nursing leadership, operational leaders and administrators
Demonstrated ability to support process improvement and organizational change initiatives

Nice To Haves

Master’s degree in Healthcare Administration, Nursing, or a related field is preferred (must provide official transcripts at time of interview)
Five (5) or more years of progressive leadership experience in quality improvement, patient safety, or performance improvement within a healthcare setting is preferred
Experience supporting physician quality review or peer review processes strongly is preferred
Experience conducting chart audits, clinical reviews and operational investigations
Licensed as a Registered Professional Nurse in the State of Illinois is preferred
CPHQ, CPPS or other quality/safety certification is preferred (must provide proof at time of interview)
Professional certification in quality, patient safety, or process improvement (e.g., CPHQ, CPPS, Lean, Six Sigma Black Belt/Green Belt) is preferred (must provide official transcripts at time of interview)

Responsibilities

Manages and oversees day-to-day peer review workflows and processes and physician quality review operations across departments and service lines.
Coordinates case reviews, collection and analysis of supporting documentation, preparation of case summaries and reports, and facilitation of peer review committee activities.
Collaborates with physician leadership, nursing leadership, quality, risk management, and medical staff services to ensure peer review activities are conducted in a timely, consistent, confidential, and effective manner.
Shares peer review findings and process improvement initiatives committee recommendations.
Supports development and implementation of peer review policies, workflows, educational materials and quality initiatives.
Tracks action items, trends and follow-up activities resulting from peer review findings and manages intake, triage, prioritization, tracking and resolution of peer review cases.
Conducts detailed chart reviews, documentation reviews and operational investigations prior to presenting to peer review committee.
Prepares peer review agendas, case summaries, timelines, supporting documentation and presentation materials.
Substantiates key operational details including documentation timing, escalation pathways, follow-up communication, and compliance with organizational protocols.
Identifies systems and process issues, workflow gaps and operational improvement opportunities through peer review activities.
Develops and maintains systems and processes to collect, analyze, and disseminate peer review information that supports informed decision-making and continuous quality improvement.
Supports peer review by ensuring operational and clinical information is complete and available prior to committee discussions.
Facilitates efficient and meaningful peer review committee operations and multidisciplinary case discussions.
Maintains peer review databases, dashboards, tracking systems and reporting tools.
Ensures peer review activities comply with organizational policies, Joint Commission standards, CMS requirements and confidentiality protections.
Participates in multidisciplinary quality, patient safety and provider professionalism initiatives as needed.
Provides regular reports and updates to provider, quality leadership and organizational committees.
Supports a just culture environment focused on learning, accountability and continuous improvement.
Performs other duties as assigned.