Medical Staff Quality & Performance Coordinator

Emerus

80d

About The Position

The purpose of this position is to lead, implement and oversee a comprehensive Medical Staff quality program, with a focus on peer review, performance evaluation, and cross-departmental collaboration. This role plays a critical part in ensuring physician accountability, improving patient safety, and enhancing the flow of quality data across the system.

Requirements

• An unencumbered and current license as a Registered Nurse (RN) in one of the US states, required.
• 2+ years of clinical experience as an RN, required.
• Previous experience in peer review, case management, quality oversight, clinician education or similar, required.
• Bachelor of Science in Nursing, required.
• Strong knowledge of accreditation standards with DNV, state, federal laws, required.
• Comprehensive knowledge of medical staff office functions and responsibilities, required.
• Knowledge of medical-legal issues, peer review protections, and awareness of the legal ramifications of hospital documentation and compliance deficiencies, required.
• Strong proficiency with Microsoft Office (Excel, Word, PowerPoint and Outlook), required.
• Position requires fluency in English and extensive knowledge of medical terminology and technology; written and oral communication.

Nice To Haves

• Master of Science in Nursing or higher in related field, preferred.
• Experience with RL Datix system, preferred.

Responsibilities

• Assist with creation and maintenance of scorecards for ongoing and focused professional practice evaluations (OPPE/FPPE) for medical staff.
• Assist in reviewing scorecard data to identify performance issues.
• Conducts peer review activities including case review, documentation, committee presentation, and follow-up on recommended actions.
• Collaborates with Quality, Risk, Medical Directors to address physician performance and safety concerns.
• Works in collaboration with the Patient Safety Organization on enhancing physician processes to improve patient safety.
• Reviews and recommends improvements to peer review policies and procedures.
• Assists in the establishment and maintenance of a system-wide peer review committee to standardize processes and enhance oversight.
• Supports the implementation and continued use of a new peer review module, including training and workflow integration.
• Contributes to building a robust medical staff-centered quality program that ensures physician outliers are identified and addressed beyond the facility level.
• Attend staff meetings or other company sponsored or mandated meetings as required.
• Perform additional duties as assigned.
• Ability to work off-hours and on call when required.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees