Summary

The Medical Quality Coordinator coordinates an effective medical staff peer review process that supports medical staff reappointment, advancement, and clinical quality in compliance with performance evaluation standards (OPPE and FPPE) and CMS regulations. Coordinates all aspects of the peer review quality program, to include referrals related to professional leadership behavior. Conducts clinical reviews of medical records using critical thinking skills, pre-approved clinical indicators based on established definitions for peer review for assigned populations and provides timely feedback to executives, clinical management and physicians to ensure optimal quality patient care.   

Responsible for Peer Review program assessment, planning, organizing, implementation, performance improvement, and education of staff throughout the organization.

  Essential Duties and Responsibilities 

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.  

Collaborate with Medical Staff and Quality Data Analyst to develop effective mechanisms to respond to medial quality concerns Work to create action plans in collaboration with the Medical Staff Work with the Quality Data Analyst using Premier Analytic system and other databases to develop reports regarding external benchmarking and performance standards Serve as a resource to facilitate communication among medical staff members and medical staff office personnel in the credentialing and reappointment process Coordinate the Medical Staff Peer Review Committee (known as PEC) and the Professional Excellence Committee (PLC) by conducting clinical chart reviews, maintaining minutes, preparing letters, and tracking all follow-up items. Work with the Medical Staff Peer Review Committee Chair, the Professional Leadership Committee Chair and the Chief Medical Officer (CMO) to address concerns. Keep them informed regarding medical staff quality and professional behavior referrals and findings Evaluate opportunities to improve the outcomes related to patient service excellence Facilitate the utilization of current information technology resources to enhance the efficiency of the peer review process, credentialing, and the reappointment process Perform biannual physician profile data reviews to identify outliers; make data collected available to medical staff for review Effectively manages assigned projects with a level of independence in performance of the role and/or solution of problems. Identifies and prepares safety stories and safety messages for use at meetings and huddles  Actively participates as the department representative in designated multidisciplinary teams and committees Support clinical operations and clinical initiatives as assigned Attend required hospital-wide orientations, meetings, and in-services Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care Education and Experience 

Minimum Required Education: Bachelor of Science in Nursing (BSN)

Preferred Education: Masters of Science in Nursing (MSN)

Experience: 5+ years' experience in one or more of the following areas - performance improvement, clinical work, Quality Management, Medical Staff credentialing

Certificates, Licenses, Registrations 

Applicant must be licensed to work as a Registered Nurse in the Commonwealth of Virginia, and must obtain CPHQ certification within 2 years of hire. BLS required.