CentraState Healthcare System

  • Medical Staff Quality / Peer Review Coordinator

    Posted Date 2 weeks ago(4/5/2018 1:04 PM)
    Position Type
    Regular Full-Time
    CentraState Medical Center
  • Overview

    The purpose of this position is to ensure quality patient care by effectively managing the Medical Staff’s Quality Improvement and Peer Review Processes.  The Medical Staff Quality/Peer Review Coordinator is responsible for the coordination of the quality improvement activities of the Medical Staff in cooperation with the Physician Advisor, Medical Staff Officers, Medical Director, Medical Staff Committees and Chairpersons, Vice President of Quality and Patient Safety and the Staff of the Office of Medical Affairs.


    • Responsible for the coordination of Ongoing and Focused Professional Practice Evaluations (OPPE/FPPE) for all Medical Staff members including the maintenance of reports, scheduling of reports, content of reports, collection of data, completion by Medical Staff Leadership in a timely manner, adherence to regulatory body standards.
    • Analyze and present department specific and provider specific analytics regarding performance.
    • Responsible for coordinating the Peer Review Process.
    • Refers quality issues to Medical Education as appropriate for inclusion in CME programs.
    • Stays familiar with all aspects of the Director of Medical Affairs (MA) role in order to provide support to the staff in his/her absence.
    • Works with the Office of Medical Affairs, Medical Staff officers, and the Chief Medical Officer on special projects, as needed.
    • Develops and maintains user expertise with all systems supporting job function Prepares agendas, attends, develops and circulates minutes of the monthly Medical Staff Quality Improvement/Risk Management meetings and introduces relevant topics based on quality issues.
    • Participates in the performance of case reviews pursuant to medical staff screening criteria and algorithms; collaborating with Medical Staff Quality Improvement physician, department and division Chairpersons to ensure objective review of referred cases.
    • Provides required data to Medical Staff Affairs related to the re-credentialing process



    Bachelor’s Degree in Healthcare required.


    Work Experience:

    Three years of clinical hospital setting experience required.

    Three years of quality assurance and improvement experience required.


    Licenses and Certifications:

    Certification in Medical Staff Management (CPMSM) preferred.

    Healthcare Quality (CPHQ) preferred.


    Required Knowledge and Skills:

    Medical terminology knowledge required.

    Computer knowledge including word processing, spreadsheets and database management required.

    Proficiency in Crimson Clinical Advantage or similar physician performance evaluation software.

    Physical Demands

    Working Conditions:

    Normal office environment with frequent visits to locations across the System and off-site.



    No expected exposure to blood and/or body fluids.


    Physical Demands:

    Sitting - Frequently

    Standing/Walking – Occasionally

    Kneeling/Stooping - Never

    Bending/Climbing - Never

    Reaching above shoulder, at waist or below waist - Never

    Lifting/Pushing or Pulling up to 40 pounds - Never

    Lifting/Pushing or Pulling over 40 pounds - Never

    Typing/Filing - Frequently



    Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


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