Job Description

* All positions are located in Fresno/Clovis CA*

Responsibilities

The Medical Staff Ongoing Professional practice Evaluation (OPPE) / Focused Professional Practice Evaluation (FPPE) Coordinator collaborates with the RN OPPE / FPPE Coordinator to collect, analyze, and report performance metrics for Medical Staff members across CMC. This role ensure compliance with the Joint Commission requirements to ensure Medical Staff members can safely and competently provide care. Duties will support key credentialing, privileging, and continuous professional development processes. The coordinator will collaborate with the Medical Staff President and other leadership to identify trends, monitor clinical performance, and provide actionable insights that enhance patient safety and care quality. Job DescriptionEssential AccountabilitiesReflects the job's main responsibilities and is not intended to be an exhaustive list of all duties performed; therefore, its content does not restrict management's right to assign or reassign duties and responsibilities to individuals in this job.o Performs in-depth proactive clinical analysis for confidential physician issues related to patient safety, peer, and quality.o Serves as the technical expert to design, maintain, and refine OPPE and FPPE dashboards and reports for medical staff members.o Identifies performance trends and outliers, providing recommendations for improvement.o Demonstrates ability to develop data spreadsheets and provides the analysis and communication to interpret data into information in order to drive quality and change.o Ensures OPPE and FPPE processes meet the Joint Commission and CMS requirements.o Works to align OPPE indicators with publicly reported Quality measures as appropriate.o Collects and analyzes data on clinical outcomes, patient safety events, documentation quality, and patient experience.o Works with employees and physicians to investigate confidential quality, behavioral, and patient safety concerns.o Partners with Department Chairs, service line leaders, and Medical Staff committees to review performance data.o Demonstrates ability to develop data spreadsheets and provides the analysis and communication to interpret data into information in order to drive quality and change. Facilitates turning data into information for point of service staff and performance improvement.o Assists in survey readiness and compliance audits.o Develops and assists with implementation of action plans focusing on quality outcomes and performance improvement projects using physician and staff input.o Provides education and guidance to medical staff on OPPE / FPPE metrics and expectations.o Facilitates discussions on performance improvement plans when metrics fall below thresholds.o Develops clear, concise reports for the Medical Executive Committee, Credentialing Committee, MSPRC, PBC, and Hospital Leadership.o Translates complex data into actionable insights for clinicians and administrators.o Maintains confidentiality and integrity of medical staff performance data.o Understands and makes appropriate referrals to Risk Management, Peer, Quality Management, or clinical operations as needed.o Utilizes facilitation skills, coaching and mentoring of groups, (internal and external) physicians, and staff, including design, development and implementation of new processes.o Performs other job-related duties as assigned. Knowledge, Skills, and Abilitieso Extensive knowledge of Medical Staff, hospital, and clinical operations relating to regulatory, risk, peer, and performance improvement.o Current knowledge of the Joint Commission, Title 22, CMS Conditions of Participation, and other regulatory requirements.o Knowledge of evidenced-based medicine standards of care (e.g, cardiac care through American College of Cardiology).o Fundamentals and practices of nursing specialties.o Writing and communication skills.o Proficient use of Microsoft Office programs such as Excel and Word.o Strong problem-solving skills to tackle tough analytical challenges.o Establishing and maintaining effective working relationships with those contacted in the course of work.o Ability to communicate effectively in both written and verbal form to physicians and management staff.

Qualifications

Educationo Bachelor's Degree in Health Care Management, Public Health, Informatics or related field required Experienceo 3 years of experience with project management and quality improvement required. Licenses and CertificationsOne of the following is preferred:o CPMSM - Certified Professional in Medical Services Managemento CPHQ - Certified Professional Healthcare Qualityo NATIONAL - National Certification related to specialty and applicable to role

Disclaimers

• Pay ranges listed are an estimate and subject to change.• If any bonuses are noted, they are only applicable to external hires meeting criteria.