Description -External

Peer Review Coordinator RN BSN

All the benefits and perks you need for you and your family:

Benefits from Day One

Paid Days Off from Day One

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: PT - Wed-Thursday 20 hours (virtual 16 hours and on-site 4 hours)

Shift : Days

Location: 1035 Red Bud Road, Calhoun, GA 30701

The community you’ll be caring for: AdventHealth Gordon

Four seasons of outdoor activities, including whitewater, hiking, camping

Named #4 on NICHE magazine’s “Best Cities (under 100,000) to Raise a Family”

Affordable land and homes

Outstanding qualify of life

Strong cultural community

Access to excellent public and private K-12 education

Convenient location between two large metropolitan areas: Atlanta and Chattanooga

The role you’ll contribute:

GENERAL SUMMARY :

The Peer Review Coordinator is responsible for conducting various activities and duties related to the peer review process. Responsible for facilitation and implementation of all aspects of the medical staff peer review process including medical record review of cases meeting established indicators, preparation of case summaries for physician review and follow-up as required. Responsible for development and revisions of department specific procedures for activities related to the peer review process.

Responsible for implementation/coordination of the Focused Professional Practice Evaluation (FPPE) review process for practitioners with new privileges and/or new procedure(s) and maintains database of results. Responsible for the Ongoing Professional Practice Evaluation (OPPE) review process which may also result in the need for FPPE. Maintains databases of physician peer review credentialing/re-credentialing, and quality improvement activities through utilizing various software programs. Prepares a variety of reports utilizing statistical/graphic software. Responsible for compliance with The Joint Commission and Healthcare Facilities Accreditation Program Medical Staff standards relative to the peer review process.

Serves as the Adventist Health System Mortality Initiative Patient Safety Organization (PSO) component owner and practices with minimal supervision, skilled in listening to care providers, interpreting data, and evaluating the needs of those involved in the process of patient care delivery.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES :

Functions as the Peer Review Coordinator for Medical Staff Peer Review and Credentialing activities relative to the Accreditation/Risk Management Department.

Maintains current knowledge of quality indicators and review methodology as evidenced by accuracy of data.

Abstracts clinically pertinent information from patient medical records to prepare summaries for review.

Prepares all needed information for monthly meetings with Medical Staff Peer Review Representatives to perform peer review.

Completes all required follow up activities and minutes in a timely manner according topre-established deadlines.

Communicates with other departments concerning information needed to complete the peer review process.

Provides data for graphic representation of peer review indicators for PIC, MEC and Board reports as well as detailed information and assists with graphs as needed.

Keeps Director informed regarding medical staff communication regarding peer review activities and notifies Director of all potentially litigious incidents identified through the Peer Review process.

Performs annual evaluation of peer review indicators with medical staff leaders and implements changes to indicators/process as indicated.

Functions as the Performance Improvement Analyst for Medical Staff Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE).

Retrieves records/procedures based on Credentialing Committee request for Medical Staff and Allied Health Members for initial privileges, additional privileges and/or requests based on identified opportunities for improvement.

Distributes request for FPPE review to applicable Physician Peer Review Representatives.

Prepares synopsis of FPPE findings and presents to the Credentials Committee.

Gathers data collected on applicable peer review indicators/denominator data and calculates rates.

Completes the credentialing reappointment profile every six months for Medical Staff OPPE activities. Presents the information to the Credentials Committee.

Compiles all required records for external review as required.

Maintains current and historical peer review files for medical staff members.

Utilizes Qual Care and other applications by accurately entering variances into the system.

Demonstrates the ability to retrieve information from all departmental software applications, in the form of lists, reports, and review sheets.

Ensures that all peer review information and files are secured and remain confidential according to Georgia statute.

Functions as the AHS Mortality Initiative Patient Safety Organization (PSO) component owner and participates in continuous process improvement activities.

Participates in the review of all mortalities and enters information into the applicable database by established due dates.

Assists in the development and implementation of quality improvement and risk reduction strategies to control loss and risk exposure for the organization. Completes activities as assigned relative to the Patient Safety Organization.

Investigates sentinel events; Functions as the facilitator for Root Cause Analysis (RCA) teams. Follows up on outcomes of RCA team results and recommendations.

Assists with other duties as assigned.

Qualifications

EDUCATION AND EXPERIENCE REQUIRED :

Graduate of an Accredited School of Nursing

BSN

A minimum of five years of nursing experience with demonstrated qualities of leadership and organizational ability.

EDUCATION AND EXPERIENCE PREFERRED:

Previous experience in Peer Review preferred.

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED :

Registered Nurse with current licensure in the State of Georgia required.

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

Certified Professional Healthcare Quality (CPHQ) preferred.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Quality/Clinical Effectiveness

Organization: AdventHealth Gordon

Schedule: Part-time

Shift: 1 - Day

Req ID: 24031854

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.