Job Description:

Job Summary

Responsible for the coordination of the Medical Staff Patient Care Committees that evaluate the quality of care provided and patient outcomes within the organization. Facilitates the clinical evaluation process including the utilization and analysis of data and sensitive information to support medical staff recommendations and actions. Gathers, compiles, and summarizes medical staff quality data utilized for the evaluation of care and to identify recommendations for improvement. Responsible for establishing effective and collaborative relationships with physician leadership and physician advisors. Responsible for integrity of data submitted/reported. Responsible for physician quality profiles necessary for reappointment. Facilitates process for focus and ongoing performance evaluation of practitioners. Contributes to ensuring compliance with Joint Commission medical staff standards and participating in the survey process. Coordination and participation of other quality committees and initiatives as determined.

Principal Duties and Responsibilities:

The following is a summary of the major functions of this individual's job. He or she may perform other duties, both major and minor, which are not mentioned below, and specific functions may change from time to time.

1. Gathers, compiles, coordinates medical staff quality data. Identifies opportunities for improvement. Utilization and analysis of data to recommend and implement changes, including performance improvement team leadership, data analysis for presentation to Medical Staff Patient Care Committees and others within the hospital for performance improvement.

2. Coordinates and manages RN Quality Medical Staff Analyst(s).

3. Coordinates medical record review by Physician Advisors and other peer reviewers Completes evaluations for physician advisors at the direction of the Executive Director.

4. Coordinates with medical staff quality team the Medical Staff Patient Care Committees and completes minutes and follow-up on all pending issues discussed. Compiles committee agendas and packets for timely distribution to members prior to meetings. Coordinates committee agendas, packets and case study preparation in advance of meetings with Committee Chairs, Chief Medical Officer and Executive Director.

5. Coordinates all other medical staff quality committees that fall under the Quality and Outcomes Management Department, including prompt completion of minutes and follow-up on all pending issues.

6. Validates data submitted/reported, ensuring data integrity.

7. Develops a data collection plan and reporting schedule for each committee/report and ensures deadlines are met including timely follow up.

8. Analyzes and interprets data related to medical staff quality using sound statistical principles.

9. Maintains current knowledge of medical/legal and peer review statutes/standards and their associated review requirements, and other regulatory and accrediting body standards, including Joint Commission standards. Serves as Co-Chair of Medical Staff Chapter in survey process.

10. Works collaboratively with Medical Staff Office completing required reports/information needed for physicians/allied health reappointments and other needs in a timely, organized process.

11. Coordinates with appropriate staff house-wide, the completion and submission of external payor/managed care/government requests, including identifying and coordinating opportunities for improvement to ensure optimal outcomes at submission.

12. Demonstrates and communicates a working knowledge and use of quality improvement principles and tools.

13. Maintains and applies knowledge of current trends and advancements in continuous quality improvement by reviewing current literature, attendance at professional conferences, and collaboration among professionals within the community.

14. Identifies own learning needs and seeks opportunities for self-growth and career advancement.

15. Attends selected meetings and/or serve as a liaison to physicians, Administration or other departments in lieu of or in addition to the Executive Director of Performance Improvements necessary.

16. Exhibits creativity to devise new approaches for medical staff quality issues.

17. Performs all other duties as assigned.

Minimum Education, Training and Experience Required:

• Bachelor’s degree with 3-5 years’ experience in medical staff quality, performance improvement and/or case management.

• Experience in collating data and analysis of information.

• Exceptional communication skills, both written and verbal.

• Working knowledge of desktop applications (Word, Excel, Powerpoint) and experience with clinical data bases.

• Leadership experience preferred.

1. CPHQ Preferred.

If you would like to be part of a growing family focused on supporting clinical excellence, teamwork and innovation, we urge you to apply now!

Employees will be expected to comply with Baptist Health’s infectious disease and vaccination policies, which include but may not be limited to compliance with BHS’ mandatory vaccination policies for influenza and COVID unless reasonable accommodations are needed under applicable law

Baptist Health is an Equal Employment Opportunity employer.