Facility: VIRTUAL-GA

Job Summary:

The Coordinator is responsible for designing and facilitating an effective Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) functions in accordance with The Joint Commission (TJC) Standards, CMS Conditions of Participation, WellStar Medical Staff Bylaws and Professional Practice Evaluation Policy. Analysis of events that require peer review and the examination of medical records as identified by clinical indicators or triggers is an integral part of this role. The Coordinator is responsible for managing and maintaining the confidentiality of the peer review process, quality records and performance improvement documentation to support the Professional Practice Evaluation Policy and Medical Staff Credentialing process. Prepares and maintains physician/APP quality documentation, quality profiles as well as other assigned physician/APP related performance improvement projects related to FPPE/OPPE. Supports the hospital Peer Review Committees and the system Patient Safety & Quality Department.

Core Responsibilities and Essential Functions:

Ongoing Professional Practice Evaluation (OPPE) and Re-Credentialing Process and Re-Credentialing Process * Monitors department triggers/indicators and identifies trends and outliers. * Aggregates, analyzes and communicates the OPPE summary to the system Safety and Quality Department and Business Unit Medical Director upon completion. * Supports the Medical Staff and Safety & Quality Departments by evaluating or driving improvement in individual provider performance through further retrospective case review, FPPE, Performance Improvement Plan, additional education, prospective monitoring, and other. * Populates and maintains performance files and/or dashboards for Facility Safety & Quality Departments. * Analyzes medical staff indicators which may include patient safety indicators, mortality and hospital acquired conditions to identify cases needing further investigation and/or review, as needed * Abstracts and gathers objective data from the patient record and enters OPPE template. * Responsible for complete, accurate, timely abstraction and data entry. Supports Focus Professional Practice Evaluation (FPPE), Privileging, and Credentialing Process * Works closely with Medical Staff Coordinators to identify all providers who are requesting new privileges or additional privileges, as needed * Conducts retrospective reviews on designated independent cases and compiles a summary to the facility quality department upon completion. * Collaborates with the local quality departments to define and develop performance monitoring for a practitioner with issues affecting provision of safe high-quality patient care. * Populates and maintains practitioners electronic quality files to ensure performance reports and dashboards are accurate. * Adheres to all procedures within the Professional Practice Evaluation Policy and/or Medical Staff Policies that guide the FPPE activities. Peer Review Operations * Manages and facilitates timely completion of professional practice evaluations or requirements. * Communicating with the system safety & quality department about any concerns identified in the professional practice evaluation process. * Supports the facility and system Safety & Quality Department through analysis of aggregate data expanding scope of analysis beyond practitioner related issues * Collaborates with system data analyst to provide additional data/drilldown and chart review as needed. * Assists with metric creation that is supported by clinical evidence. * Conducts chart review to understand the data; utilizes pre-determined criteria in chart review to ensure consistency of the review. * Communicates and collaborates with hospital PICs, service line quality committees, and system safety and quality department. * Collaborates with other disciplines to understand opportunities; works to align physicians, team members, and administration in an effort to focus on common clinical processes of care. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelor's Degree Required and Nursing or healthcare-related field, strongly Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Cert Prof Healthcare Quality-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 5 years years experience in nursing or relevant clinical practice. Required and Minimum 2 years of experience in OPPE/FPPE case review or other medical case review duties Required and Experience with data sources including electronic medical records and familiarity with clinical documentation. Required

Required Minimum Skills:

Proven ability to analyze, interpret, and display data; strong attention to detail; meticulous accuracy and thoroughness. In depth knowledge of medical terminology. Superior organizational and interpersonal skills with ability to work independently as well as with a team. Demonstrated excellence in interpersonal and written communication skills required. High degree of professionalism, discretion, and confidentiality. Strong computer skills with Microsoft Office. Ability to facilitate and apply critical thinking skills to resolve issues or problems and negotiate teams to reach consensus. Ability to build relationships and foster communication among stakeholders in clinical and non-clinical settings.