Position Objective:

Under general supervision, coordinates the Medical Staff Peer Review Program. Ensures the Program meets Joint Commission, CMS, Medical Staff Bylaws and other regulatory requirements. Ensures the availability of data to evaluate the initial and ongoing quality of care and competency of the Medical Staff.  Aggregates and reports clinical competency and other data to Medical Staff Leadership and Medical Center Leadership.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Reviews Joint Commission, CMS, and other regulatory requirements to ensure ongoing compliance of the Medical Staff Quality Review Program, and collaborates in the modification of the program as required.
2. Reviews Medical Staff Bylaws, Department and Service Rules and Policies to ensure ongoing compliance of the Medical Staff Quality Review Program, and collaborates in the modification of the program as required.
3. Coordinates the Medical Staff Peer Review process in conjunction with the Department Chairs and designated Medical Staff.
4. Obtains, enters, organizes, and maintains the electronic Peer Review data base to facilitate accurate Medical Staff Quality records.
5. Operates and facilitates monthly Medical Staff Quality Review Committee meetings
6. In cooperation with the Department Chair participates in the education of Medical Staff in regards to the Medical Staff Quality Review Process.
7. Coordinates the process to assess Medical Staff initial and ongoing competency through Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE). The Coordinator then reports results to Medical Staff Leadership and the Credentials team.
8. Reviews and analyzes FPPE and OPPE reports to identify and refer potential practice issues and opportunities for improvement.
9. Accesses internal and external databases to provide Medical Staff volume, outcomes, and other information as requested.
10. Partners with multidisciplinary teams throughout the Medical Center and System to identify opportunities for improving the Quality Review Program.

Educational/Experience Requirements:

• Graduate of accredited school of nursing.
• Five to eight years of experience as a Registered Nurse.
• Experience with performance improvement techniques preferred.
• Computer skills preferred.

Required License/Certifications:

• Licensed RN by the Maryland Board of Nursing Required

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.