Under the direction of the Director of Medical Staff Services, is responsible for activities at Gila Medical Center which supports the Mission, Vision, Goals and Values of the organization and promotes high-quality patient safety services. Works independently and in collaboration with team members to identify/implement/and support strategies to improve the quality of care to and safety of the patients and the Medical Center.
Is responsible for abstracting Provider quality data; tracking and trending performance initiatives and indicators;
Coordinates and analyzes and develops data for periodic appraisals
Is responsible for coordinating and processing Ongoing Professional Performance Evaluations and Focused Performance Evaluations within the guidelines of, TJC, CMS, State and Federal mandates and best evidenced based practice.
Provides for timely and accurate collection, transmission, analysis and reporting of Center for Medicare / Medicaid Services and The Joint Commission, NPDB, and Peer Review statutes.
Abstracts clinical data from inpatient, outpatient, and Behavioral Health Unit visits following the rules in the Specifications Manuals for Hospital Quality Measures, HIPAA, and Peer Review statutes.
Maintains the Medical Staff’s peer review and performance improvement program as directed.
Maintains meticulous records peer review and periodic appraisals records as directed
Supports, maintains, and coordinates peer review.
Completes and maintains reports such Track and Trend, OPPE, FPPE, and data validations.
Plays a key role in the hospital’s patient safety initiatives, including practitioner education, development and identification of variations in care.
Works collaboratively with key department and individuals in developing strategies and initiatives to improve compliance with Medical Staff goals, objectives and initiatives.
Conducts or assist with focus studies, when appropriate, to support Medical Staff quality initiatives and Medical Staff performance improvement activities.
Provides support for the hospital’s Medical Staff performance improvement and strategic goals.
Facilitation of improvement opportunities peer review processes and procedures
Responsible for ensuring appropriate improvement follow-up occurs and effective collaboration with appropriate owner when needed.
Monitor and report Medical Staff performance improvement department patient safety initiatives to Medical Staff Services Director.
Performs monitoring/auditing based on organization needs and report findings.
Track, trend, and report concerns to ensure improvement
Associate’s’ s degree in nursing or other healthcare administrative profession; or a combination of comparable healthcare administration or clinical education and / or experience
Certified Medical Staff Services Professionals or Certified Professionals in Healthcare Quality preferred
Three to five years of experience with Medical Staff Services, Peer Review, QI standards, clinical chart review and abstraction, and regulatory requirements preferred
In-depth knowledge of, Performance Improvement models, tools, and techniques, including collection, abstraction, validation, analysis, visualization, reporting of data, use of performance and benchmark indicators
Advanced organizational and project management skills, with the ability to prioritize tasks, see projects through from inception to completion on schedule
Attention to detail is essential
NOTE: Job description available on request.
**All required documents must be presented at time of hire.**
EXTERNAL APPLICANT: Employment is contingent upon successful completion of