Position Title:

Quality Coordinator-Medical Staff Services

Department:

Medical Staff/Credentialing

Job Description:

General Description:

Responsible for coordination and managing the medical staff's performance improvement activities, including, but not inclusive of peer review activities, Ongoing Professional Performance Evaluation (OPPE), Focused Professional Performance Evaluation (FPPE).  Activities include data collection, analysis, facilitation of development of quality indicators and recommendations for improvement.  Reports to the Medical Staff Services Director and collaborates with the Peer Review Committee, Credentials Committee, and Medical Staff Leadership to support medical staff quality initiatives.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position. 

• Coordinates hospital quality & performance measure collection. This may include use of outside vendor products (i.e., Vizient) to enhance the review of such data.
• Maintains and supports the quality database(s) used to track quality data.
• Works with each Clinical Service Line to develop and maintain OPPE indicators on a routine basis.
• Reviews incoming Medical Staff quality data from the multiple sources to determine if outliers are needed for review and facilitates the appropriate follow up or Medical Staff Committee Review of such outliers.
• Works with the hospital data regarding quality events and potential concerns to help determine if there is a potential outlier that requires Medical Staff follow up and/or intervention.
• Review each providers OPPE/FPPE data per policy and then reviews the data with the Service Line Chief.  
• If a provider is an outlier, assists the Service Line Chief in developing an action plan to be presented to the appropriate Medical Staff Committee(s).
• Is knowledgeable about credentialing and privileging processes within Medical Staff Services as it pertains to quality.
• Maintains meaningful OPPE scorecards that can be presented to the Credential's, MEC and Board of Directors about the quality of any practitioner seeking re-appointment.
• Oversees and manages the ongoing monitoring of national practitioner databank reports, action on licensure and government sanctions to identify trends and proper review by the applicable Medical Staff Committees.
• Collaborates with Medical Staff Leadership and the Medical Staff with quality initiatives.
• Educates the applicable departments on mandatory quality initiatives, and hospital-based quality initiatives. 
• This includes reviewing FPPE plans with providers who need them, helping to on-board new physicians, and educating Medical Staff leaders, Peer Review and Credentials committee members as needed.
• Assists the Medical Staff when new equipment, technology, or procedures are sought after to establish and operationalize quality indicators, for the new procedure.
• Assists medical staff leaders in creating new FPPE parameters when new privilege criteria are created to align with new equipment and/or technology.
• Helps facilitate the monthly agendas for Peer Review Committee and Credentials Committee regarding FPPE, OPPE and other quality initiatives. 

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education:  Associate degree required, Bachelor’s degree or Registered Nurse (RN) preferred

Experience: 4+ years’ experience in quality resources/department, processes and procedures.  Must have a solid foundation and understanding of the credentialing and privileging workflows.

Licensure/Certifications/Registrations Required:  Certified Professional in Healthcare Quality (CHPQ) - National Association for Healthcare Quality (NAHQ) or other related Quality certification (preferred)

Knowledge, Skills and Abilities:  

• Knowledge of accreditation standards and legal requirements related to medical staff services, credentialing and privileging.
• Knowledge and experience with EPIC to pull appropriate data for medical staff peer review purposes and case log data.
• Experience with basic data analysis; proficient in using data to inform decisions
• Excellent verbal and written communication skills.

• Knowledge of credentialing software and associated applications strongly preferred. 
• Ability to work under minimal supervision and to adapt quickly to changes within the environment 
  • Ability to maintain confidentiality
  • Proficient knowledge of Microsoft Word, Excel, and Outlook

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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.