Job Description - MANAGER OF PEER REVIEW (00139432)
Job Description
MANAGER OF PEER REVIEW
Requisition ID
: 00139432
Job Posting
: Sep 1, 2026, 7:33:57 PM
Closing Date
: Sep 16, 2026, 10:29:00 AM Full-time Shift Start Time: 8:00 A.M. Shift End Time: 4:00 P.M.
Collective Bargaining Unit: NONE Posting Salary: $109,309-$120,675 YEARLY
Organization
: Health and Hospital Systems
DEPARTMENT / LOCATION: QUALITY ASSURANCE / STROGER
SHIFT: 8AM-4PM
This position is exempt from Career Service under the CCH Personnel Rules.
Job Summary
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.
General Administrative Responsibilities
Collective Bargaining
- Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
- Participate in collective bargaining negotiations, caucus discussions and working meetings
Discipline
- Document, recommend and effectuate discipline at all levels
- Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
- Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Supervision
- Direct and effectuate CCH management policies and practices
- Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Management
- Contribute to the management of CCH staff and CCH' systemic development and success
- Discuss and develop CCH system policies and procedures
- Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
- Work with Labor Relations to discern past practice when necessary
Typical Duties
- 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.
Minimum Qualifications
- 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
Preferred Qualifications
- 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)
Knowledge, Skills, Abilities and Other Characteristics
- 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
Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, "Typical Duties" are essential job functions.
BENEFITS PACKAGE
- Medical, Dental, and Vision Coverage
- Basic Term Life Insurance
- Pension Plan
- Deferred Compensation Program
- Paid Holidays, Vacation, and Sick Time
- You may also qualify for the Public Service Loan Forgiveness Program (PSLF)
- 100% Tuition Reimbursement for nursing-related programs
For further information on our excellent benefits package, please click on the following link: http://www.cookcountyrisk.com/
- Degrees awarded outside the United States with the exception of those awarded in one of the United States'' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.
- Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
- CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER