Job Description

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