Peer Review and Professional Practice Evaluation Coordinator (RN)

Montage Health•Monterey, CA

5d•Onsite

About The Position

The Peer Review and Professional Practice Evaluation Coordinator is responsible for coordinating and supporting the hospital’s physician peer review, Ongoing Professional Practice Evaluation (OPPE), and Focused Professional Practice Evaluation (FPPE) processes for credentialed and privileged providers. The role ensures provider performance evaluation activities are timely, consistent, confidential, and compliant with Medical Staff Bylaws, applicable policies, The Joint Commission standards, CMS Conditions of Participation, and state regulatory requirements. The Coordinator supports the professional practice evaluation lifecycle by reviewing and summarizing clinical information, coordinating peer review activities, tracking OPPE and FPPE requirements, preparing reports for medical staff leaders and committees, and maintaining accurate documentation in credentialing, privileging, quality, and peer review systems. The role collaborates with medical staff leadership, department chairs, peer reviewers, Quality, Risk Management, Medical Staff Services, and other stakeholders to support patient safety, quality improvement, and regulatory readiness. This position reports directly to the Manager of Medical Staff Services and works in close collaboration with the Director of Quality on physician performance evaluation, peer review, patient safety, and quality improvement initiatives. It requires a full-time onsite presence.

Requirements

Current, active, and unrestricted California Registered Nurse license.
Demonstrated ability to maintain confidentiality and discretion regarding sensitive provider performance and peer review information.
Strong analytical skills, including the ability to identify trends, documentation gaps, and process improvement opportunities.
Excellent written and verbal communication skills.
Strong organizational, project management, and time-management skills.
Ability to prioritize multiple competing deadlines.
Ability to work independently and collaboratively with interdisciplinary teams.

Nice To Haves

Bachelor's degree in Nursing (BSN) preferred; an Associate degree in Nursing with relevant experience may be considered.
Experience supporting Medical Staff Services, credentialing, privileging, physician peer review, or healthcare quality.
Experience with OPPE/FPPE program administration.
Experience using credentialing, quality management, or peer review software.
Knowledge of accreditation standards, including The Joint Commission and CMS Conditions of Participation.

Responsibilities

Coordinate physician peer review activities, including case intake, tracking, committee preparation, follow-up, and documentation.
Review, analyze, and summarize medical records and clinical events for peer review and professional practice evaluation.
Assist in developing, implementing, and evaluating OPPE metrics and reports to support assessment of provider competence and safe, high-quality patient care.
Prepare and maintain OPPE and FPPE reports, provider quality profiles, dashboards, tracking logs, and summary documents for medical staff leaders and committees.
Coordinate peer review committee meetings by preparing agendas, compiling case materials, documenting findings and recommendations, distributing follow-up communications, and tracking action items.
Maintain timely and accurate peer review, OPPE, and FPPE data in credentialing, privileging, quality, or peer review software systems.
Maintain current knowledge of Medical Staff Bylaws, Rules and Regulations, policies, The Joint Commission standards, CMS requirements, and applicable state and federal regulations related to peer review and professional practice evaluation.
Collaborate with department chairs, medical staff leaders, Quality, Risk Management, Information Technology, and Medical Staff Services to collect, validate, analyze, interpret, and report provider performance data.
Track cases referred for peer review from quality reports, patient complaints, clinical indicators, adverse events, department referrals, or other approved sources.
Analyze provider performance data and identify trends, patterns, improvement opportunities, and potential concerns requiring further review.
Support accreditation survey and regulatory review readiness by maintaining complete, accurate, and readily retrievable peer review and professional practice evaluation documentation.
Provide education, guidance, and support to providers, medical staff leaders, and internal stakeholders regarding OPPE, FPPE, and peer review processes.
Support policy and procedure development related to professional practice evaluation and contribute to process improvement.
Adhere to organizational policies, procedures, safety standards, privacy requirements, and confidentiality expectations.
Complete required training, in-services, continuing education, and competencies within established timeframes.
Maintain professional communication and collaboration with providers, leaders, colleagues, and interdisciplinary partners.
Support a culture of quality, patient safety, accountability, and continuous improvement.
Perform other related duties as assigned.