Davis Health System
Performance Improvement Specialist- Med Staff
Davis Health System, Morgantown, West Virginia, United States, 26501
Performance Improvement Specialist Med Staff (Job ID: 34359)
Job Summary
Under the direction of the Vice President of Medical Affairs and in collaboration with Medical, Allied Health Professional and hospital staff, the Medical Staff Performance Improvement Specialist applies clinical knowledge to assure the Medical Staff Peer Review process is effective in evaluating issues related to professional practice. They are responsible for collection, analysis, and reporting of data as it relates to performance improvement activities, provider peer review, and data used in consideration for appointment/reappointment during the Credentialing process. They develop accurate clinical case summaries, data trending, reports and analysis for Medical Staff Leadership consistent with guidelines established by the Medical Staff department and regulatory agencies. This position is responsible for overall management of the physician and allied health professional peer review process including, tracking committee recommendations and follow-up actions for timeliness of response. The Medical Staff Performance Improvement Specialist assists the Vice President of Medical Affairs with physician performance initiatives, manages medical staff projects, and coordinates clinical and non-clinical performance improvement in compliance with organizational goals and regulatory standards.
Responsibilities
Peer Review & Performance Improvement Manages, monitors performance and provides oversight to peer review processes across the organization to assure process effectiveness, timeliness, consistency and compliance with organizational policy. Directs management of the peer review workflow from acceptance of cases for peer review, facilitation of initial screening if applicable, preparation of peer review materials, documentation of peer review results, production of reports and maintenance of peer review databases. Attends Medical Staff Peer Review Committees as a staff person and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee as appropriate. Manages day-to-day regulatory systems and other confidential communications related to findings of peer review committees in accord with organizational policy and medical staff bylaws, rules and regulations. Participates as a non-voting member of the Credentials Committee. Completes a peer review committee clinical summary form for each case requiring review. Assigns each case to a member of the Peer Review Committee for review. Notifies the Peer Review Committee members when their assigned cases are ready for review. Remains aware of partnerships, expertise, and biases when assigning cases to peer reviewers. Performs chart reviews/ audits/ investigations/ assessments to determine areas for improvement. Identifies quality issues and determines compliance with quality and regulatory initiatives as part of the peer review process. Assists in or manages performance improvement and quality evaluation projects supporting clinical improvement opportunities. Coordinates and communicates with physicians, providers and other clinical professionals regarding screening and presentation of cases for peer review and/or regarding performance improvement projects. Initiates follow-up planning processes and activities and collaborates with hospital staff and medical departments as needed. Manages information and supports medical staff leadership to assure accountability for follow-up responsibilities. Maintains knowledge of The Joint Commission and Centers for Medicare and Medicaid Services requirements pertaining to the medical staff processes, such as credentialing and peer review. Monitoring and Reporting Manages, monitors performance and provides oversight to peer review processes across the organization to assure process effectiveness, timeliness, consistency and compliance with organizational policy. Attends Medical Staff Peer Review Committees and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee as appropriate. Manages day-to-day regulatory systems and other confidential communications related to findings of peer review committees. Coordinates Peer Review Committee activities on a routine basis including scanning for cases and facilitating meetings, and documentation and reporting. Maintains knowledge of regulatory standards and Centers for Medicare and Medicaid Services requirements pertaining to the medical staff processes. Investigates, researches and gathers information necessary to support effective reviewer and committee interpretation, evaluation and intervention related to potential opportunities for improvement. Provides data abstraction, analysis and reporting of trends. Enters data into specific databases, ensures data accuracy, and questions absence of required data elements. Maintains accurate record keeping in collaboration with other providers and department. Education and Teaching Educates participants in and facilitates the functions of the Medical Staff (hospital) peer review committees to achieve the purposes of the peer review process; serve as a consultant, as needed, to nursing and other organizational peer review committees. Consults with management and advises on educational solutions to meet physician and/or staff needs. Provides provider and organizational education regarding the peer review process; Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as a preceptor, mentor and resource to less experienced staff. Quality Management Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) process when needed. Serves as a resource within the organization for the process improvement and assessment practices including those related to accreditation by Joint Commission and other agencies. Supports and promotes organization's Quality initiatives. Understands the concept of, and is committed to, the organization's Mission by demonstrating behaviors consistent with the belief statements. Commits to self-directed growth, e.g., computer training, continuing education. Serves as a member on Quality Improvement teams. Actively participates on organizational committees; positively represents the department, speaking up and constructively contributing to the discussion and taking on extra work from the committee. Serves on a minimum of one council/committee in the role of liaison. Develops and implements unit-based Process Improvement activities. Is knowledgeable and able to assist in all areas of the Medical Staff Office. Takes the initiative to step in and assist coworkers with work while managing to accomplish own duties accurately and in a timely manner. Effectively manages competing priorities. Maintains well-designed and well-organized files (paper and computer), making it easy to quickly retrieve information. Assists the Vice President of Medical Affairs in the preparation, compliance and education of staff for continuous readiness for surveys by Joint Commission and other regulatory agencies. Leadership In Collaboration with Medical Staff leadership, drives quality and consistency in MHS Medical Staff initiatives and operating procedures. Assists with management and leadership of Medical Staff projects to ensure participation and completion. Acknowledges and appreciates each team member's contributions. Generates enthusiasm among team members. Proactively seeks opportunities to improve operations and execution. Develops and fosters relationships with business stakeholders. Works with leadership to ensure resource owner responsibilities are accepted and appropriately staffed. Performs Other Duties as Required Attends mandatory in-services, staff meetings, and actively participates in self-education. Completes all required competency assessments on time. Maintains required job knowledge (e.g. licensure and credentials, continuing education etc.). Performs other related duties and participate in special projects as assigned.
Knowledge, Skills & Abilities
Frequent lifting and/or carrying of objects weighing up to 10 lbs with a maximum lifting of 25 lbs. Minimum of (3) years' RN experience in a hospital setting, multispecialty clinic, health insurer or other diverse clinical environment with exposure to multiple specialty areas. Demonstrated knowledge in Quality Management Process Improvement, medical staff peer review, Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) preferred. Must be familiar with Joint Commission standards. Experience in a self-directed role and/or management. Computer proficiency in EHR and use of tools for data review and management.
Education• Associate's Degree (Required)• Bachelor's Degree
Credentials• Registered Nurse (Required)• Cert Prof in Healthcare (Required)
Work Schedule:
Days
Status:
Full Time Regular 1.0
Location:
Mon Health Medical Center Main Campus
Location of Job:
Mon Health Medical Center
Talent Acquisition Specialist:
Lotoya A. Henry-Ojugbana lotoya.ojugbana@vandaliahealth.org
Job Summary
Under the direction of the Vice President of Medical Affairs and in collaboration with Medical, Allied Health Professional and hospital staff, the Medical Staff Performance Improvement Specialist applies clinical knowledge to assure the Medical Staff Peer Review process is effective in evaluating issues related to professional practice. They are responsible for collection, analysis, and reporting of data as it relates to performance improvement activities, provider peer review, and data used in consideration for appointment/reappointment during the Credentialing process. They develop accurate clinical case summaries, data trending, reports and analysis for Medical Staff Leadership consistent with guidelines established by the Medical Staff department and regulatory agencies. This position is responsible for overall management of the physician and allied health professional peer review process including, tracking committee recommendations and follow-up actions for timeliness of response. The Medical Staff Performance Improvement Specialist assists the Vice President of Medical Affairs with physician performance initiatives, manages medical staff projects, and coordinates clinical and non-clinical performance improvement in compliance with organizational goals and regulatory standards.
Responsibilities
Peer Review & Performance Improvement Manages, monitors performance and provides oversight to peer review processes across the organization to assure process effectiveness, timeliness, consistency and compliance with organizational policy. Directs management of the peer review workflow from acceptance of cases for peer review, facilitation of initial screening if applicable, preparation of peer review materials, documentation of peer review results, production of reports and maintenance of peer review databases. Attends Medical Staff Peer Review Committees as a staff person and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee as appropriate. Manages day-to-day regulatory systems and other confidential communications related to findings of peer review committees in accord with organizational policy and medical staff bylaws, rules and regulations. Participates as a non-voting member of the Credentials Committee. Completes a peer review committee clinical summary form for each case requiring review. Assigns each case to a member of the Peer Review Committee for review. Notifies the Peer Review Committee members when their assigned cases are ready for review. Remains aware of partnerships, expertise, and biases when assigning cases to peer reviewers. Performs chart reviews/ audits/ investigations/ assessments to determine areas for improvement. Identifies quality issues and determines compliance with quality and regulatory initiatives as part of the peer review process. Assists in or manages performance improvement and quality evaluation projects supporting clinical improvement opportunities. Coordinates and communicates with physicians, providers and other clinical professionals regarding screening and presentation of cases for peer review and/or regarding performance improvement projects. Initiates follow-up planning processes and activities and collaborates with hospital staff and medical departments as needed. Manages information and supports medical staff leadership to assure accountability for follow-up responsibilities. Maintains knowledge of The Joint Commission and Centers for Medicare and Medicaid Services requirements pertaining to the medical staff processes, such as credentialing and peer review. Monitoring and Reporting Manages, monitors performance and provides oversight to peer review processes across the organization to assure process effectiveness, timeliness, consistency and compliance with organizational policy. Attends Medical Staff Peer Review Committees and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee as appropriate. Manages day-to-day regulatory systems and other confidential communications related to findings of peer review committees. Coordinates Peer Review Committee activities on a routine basis including scanning for cases and facilitating meetings, and documentation and reporting. Maintains knowledge of regulatory standards and Centers for Medicare and Medicaid Services requirements pertaining to the medical staff processes. Investigates, researches and gathers information necessary to support effective reviewer and committee interpretation, evaluation and intervention related to potential opportunities for improvement. Provides data abstraction, analysis and reporting of trends. Enters data into specific databases, ensures data accuracy, and questions absence of required data elements. Maintains accurate record keeping in collaboration with other providers and department. Education and Teaching Educates participants in and facilitates the functions of the Medical Staff (hospital) peer review committees to achieve the purposes of the peer review process; serve as a consultant, as needed, to nursing and other organizational peer review committees. Consults with management and advises on educational solutions to meet physician and/or staff needs. Provides provider and organizational education regarding the peer review process; Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as a preceptor, mentor and resource to less experienced staff. Quality Management Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) process when needed. Serves as a resource within the organization for the process improvement and assessment practices including those related to accreditation by Joint Commission and other agencies. Supports and promotes organization's Quality initiatives. Understands the concept of, and is committed to, the organization's Mission by demonstrating behaviors consistent with the belief statements. Commits to self-directed growth, e.g., computer training, continuing education. Serves as a member on Quality Improvement teams. Actively participates on organizational committees; positively represents the department, speaking up and constructively contributing to the discussion and taking on extra work from the committee. Serves on a minimum of one council/committee in the role of liaison. Develops and implements unit-based Process Improvement activities. Is knowledgeable and able to assist in all areas of the Medical Staff Office. Takes the initiative to step in and assist coworkers with work while managing to accomplish own duties accurately and in a timely manner. Effectively manages competing priorities. Maintains well-designed and well-organized files (paper and computer), making it easy to quickly retrieve information. Assists the Vice President of Medical Affairs in the preparation, compliance and education of staff for continuous readiness for surveys by Joint Commission and other regulatory agencies. Leadership In Collaboration with Medical Staff leadership, drives quality and consistency in MHS Medical Staff initiatives and operating procedures. Assists with management and leadership of Medical Staff projects to ensure participation and completion. Acknowledges and appreciates each team member's contributions. Generates enthusiasm among team members. Proactively seeks opportunities to improve operations and execution. Develops and fosters relationships with business stakeholders. Works with leadership to ensure resource owner responsibilities are accepted and appropriately staffed. Performs Other Duties as Required Attends mandatory in-services, staff meetings, and actively participates in self-education. Completes all required competency assessments on time. Maintains required job knowledge (e.g. licensure and credentials, continuing education etc.). Performs other related duties and participate in special projects as assigned.
Knowledge, Skills & Abilities
Frequent lifting and/or carrying of objects weighing up to 10 lbs with a maximum lifting of 25 lbs. Minimum of (3) years' RN experience in a hospital setting, multispecialty clinic, health insurer or other diverse clinical environment with exposure to multiple specialty areas. Demonstrated knowledge in Quality Management Process Improvement, medical staff peer review, Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) preferred. Must be familiar with Joint Commission standards. Experience in a self-directed role and/or management. Computer proficiency in EHR and use of tools for data review and management.
Education• Associate's Degree (Required)• Bachelor's Degree
Credentials• Registered Nurse (Required)• Cert Prof in Healthcare (Required)
Work Schedule:
Days
Status:
Full Time Regular 1.0
Location:
Mon Health Medical Center Main Campus
Location of Job:
Mon Health Medical Center
Talent Acquisition Specialist:
Lotoya A. Henry-Ojugbana lotoya.ojugbana@vandaliahealth.org