Key Responsibilities
Peer Review Coordination
· Coordinate all aspects of the clinical peer review process, including case identification, data collection, physician referrals, and follow-up activities.
· Prepare peer review cases for committee evaluation and physician review.
· Track ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) activities.
· Monitor action plans, corrective measures, and case resolutions.
Committee & Medical Staff Support
· Organize and support medical staff quality committees and peer review meetings.
· Prepare meeting agendas, minutes, reports, and supporting documentation.
· Maintain confidential committee records and peer review files.
· Ensure compliance with bylaws, policies, and confidentiality requirements.
Regulatory & Accreditation Compliance
· Assist with compliance related to medical staff quality in accordance with:
o The Joint Commission
o Centers for Medicare & Medicaid Services
o State and federal healthcare regulations
· Support accreditation surveys and audits.
· Maintain documentation required for credentialing and quality reporting.
· Provide Provider education to support medical staff compliance with regulatory standards to promote high-quality care.
Data Management & Reporting
· Collect, analyze, and maintain peer review and quality improvement data.
· Generate reports, dashboards, and trend analyses for leadership and committees.
· Monitor physician quality indicators and outcomes.
· Maintain databases related to provider performance and peer review activities.
Communication & Collaboration
· Serve as liaison between physicians, medical staff leadership, quality departments, and hospital administration.
· Communicate peer review requests and follow-up requirements professionally and confidentially.
· Assist providers with peer review documentation and process questions.
Other Duties
· Collaborate with the Quality, Patient Safety and Professional Excellence department to ensure alignment with medical staff regulatory standards, and related hospital priorities.
· Effectively manages assigned projects with a level of independence in performance of the role to include problem resolution.
· Attends required hospital-wide orientations, meetings, and in-services.
· Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest trends in field of expertise.
· Other duties as assigned.
Qualifications
Education
· Bachelor of Science in Nursing (BSN) preferred
· Active Registered Nurse (RN) licensure preferred for clinical peer review oversight roles.
· Degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field.
Experience
· Minimum of 2–5 years of experience in:
· Medical staff services
· Clinical quality improvement
· Peer review coordination
· Risk management
· Hospital administration
· Acute care hospital experience strongly preferred.
· Experience working with physicians, medical staff leadership, and accreditation standards.
Knowledge & Skills
· Knowledge of:
o Medical staff bylaws
o Peer review processes
o OPPE/FPPE standards
o Healthcare quality improvement methodologies
o Accreditation and regulatory standards
· Strong organizational and analytical skills
· Excellent written and verbal communication
· Ability to maintain strict confidentiality
· Proficiency with:
o Electronic medical records (EMR)
o Credentialing software
o Microsoft Office Suite
· Excellent analytical, organizational, and communication skills.
· Ability to maintain strict confidentiality and handle sensitive provider information.
Preferred Certifications
· Certified Professional Medical Services Management (CPMSM)
· Certified Professional in Healthcare Quality (CPHQ)
Typical Work Environment
· Hospital or healthcare system administration office
· Interaction with physicians, nursing leadership, and quality management teams
· Primarily sedentary office work with frequent computer use
· Ability to attend/lead meetings outside standard business hours