Job Description

Position Title: Quality RN Professional Practice Evaluation Specialist Position Code: QRNPPES-8030

Department: Quality Management Safety Sensitive: ☒ Yes ☐ No

Reports to: Senior Director of Quality Management Exempt Status: ☒ Yes ☐ No

Position Purpose:

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country.

The Quality RN- Practice Evaluation Specialist is responsible for collecting, analyzing, and reporting Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) process for all practitioners privileged and credentialed through the Medical Staff process. This position will interact with physicians and staff to ensure accurate collection and reporting of physician quality data to the Medical Executive Committee. Providing clinical care in compliance with evidenced-based standards is a high priority to senior leadership, the medical staff, and the board of directors . The Quality RN Practice Evaluation Specialist supports the Senior Director of Quality Management in the planning and implementation of a systematic program for monitoring provider performance and quality improvement. In conjunction with the Senior. Director, this position is responsible for ensuring compliance with regulatory requirements.

Key Responsibilities

• Prepares and analyzes OPPE reports
• Coordinates the FPPE process, working with Medical Staff Leadership to identify providers requesting new privileges, reviewing which cases are appropriate for review and referring cases for further monitoring if questions of competence arise
• Utilizes evidence-based outcomes, as a foundation, to study and improve patient care and organizational performance
• Demonstrates ability to identify unusual occurrences or trends in the data and notify Department Director.
• Works closely with Medical Staff Department Chairs to review Ongoing Professional Performance Evaluation (OPPE)
• Assists the Director in the completion of studies and projects by supporting the facilitation of the study design, data collection tools, report formats, data display, and action plans
• Working with the Department Chairman and Chief of Staff, performs an objective medical record review of each case identified regarding appropriateness of patient care based on evidence-based outcomes and clinical guidelines
• Conduct audits and provide feedback to reduce errors and improve processes and performance
• Collaborates with providers to communicate deficiencies. Assists in chart audits and abstraction
• Maintains a working knowledge of regulatory and industry wide quality indicators for Medical Staff related OPPE/FPPE
• Presents performance data to Medical Staff and Hospital Committees as requested
• Act as a liaison between Medical Staff Leadership and Quality Management Director to facilitate the flow of information
• Performs all other duties as assigned.

Qualifications

Education: Current Arizona License Required

Experience: Three (3) years clinical experience

Skills and Knowledge:

• Ability to work effectively across sites and across organizational levels.
• Demonstrated good collaboration skills.
• Excellent verbal and written communication skills.
• Excellent organizational skills and attention to detail.
• Ability to work independently and collaboratively in a fast-paced, team environment.
• Demonstrates a thorough working knowledge and competency in various computer applications.
• Ability to develop and maintain effective working relationships with co-workers and all levels of management.

Preferences

Education: Bachelor’s Degree Preferred

Experience: Medical Staff knowledge preferred

Special Position Requirements

Blood Borne Disease Category: III: Expected duties do not have potential for exposure to blood, body fluids or tissues.

Work Requirements

• Visual acuity
• Ability to sit at a computer for up to five hours a day
• Minor lifting, up to 25 pounds

Date Staff Position Description Created / Revised: 2025