Job Description:

Peer Review/OPPE/FPPE

Responsible for reviewing cases generated by chosen indicators or referred by other sources.Coordinates and facilitates OPPE/FPPE process for all physicians and allied health every month. Aid MD Advisor and committee members in their reviews.Responsible for accurate communication of MD Advisor reporting and findings to committees, addition of MD Advisor findings to database.Generate peer review worksheets and assign to appropriate committees for reviewPeer Review/OPPE tracking includes, but is not limited to, sedation with analgesia complications, lack of correlation, risk management referrals, outcomes referrals, HIM referrals, pathology, teleradiology, radiology, women’s imaging radiation oncology, and other specific tracking as requested by individual committees. Peer Review/FPPE tracking includes, but is not limited to, provisional reviews, focus reviews, and new procedure reviews.Prepares aggregated data in a monthly peer review report for MEC and the Administrative Board.Prepare aggregated data at year end by indicator, physician, and department.Prepare peer review reports for review of practitioner activity for focus review completions, or provisional status review.Report peer review information to Risk Management as directed,Reports Peer review activity and process improvement opportunities for CME credit.

Facilitates Meetings Including Documentation Follow-Up

Prepares Agenda, notifies members, attends and records actions.Organize the review of all peer review issues by the committee chair and other members.Prepares worksheets and documents for meeting.Responsible for documenting all peer review actions generated by committees, by completing all committee follow-up including minutes, letters to practitioners, communication of issues to appropriate hospital directors, and filing peer review worksheets.

Computer Knowledge

Responsible for maintaining the Credential Stream database integrity relating to peer review activity.Accurate use of Word and Excel regarding MD Advisor summaries and peer review committee review findings.Responsible for knowledge of the following software’s, Epic, Credential Stream, Premier.Runs reports in Credential Stream, Epic, Qlik, and Premier as needed for peer review or other Medical Staff Office functions.

Medical Staff Office Functions and Other Duties

Responsible for adding and deleting MDs and AHPs in the National Practitioner Data Base and forwarding any information received monthly.Responsible for Background checks for all physicians and allied health professionals.Responsible for facilitating and assisting with external and regional peer review activities/projects.Assist medical staff members and allied health professionals by providing direction for questions, concerns, or complaints,Aid with policy updates, credentialing criteria, and delineation of privilege forms as needed,Provide support for CMO/VPMA and Department Director as directed.Provides back-up for Credentials Committee and Medical Executive Committee as directed.Provides back-up for processing Initial AHP applications.Facilitates resignation process by submitting the appropriate communication to IT and ensuring termination of access.Assists with filing and facilitation of quarterly audits.Assists Director with compliance to the Medical Staff ACHC chapter.Assists Director and Credentials Coordinator with updates to privilege criteria and Medical Staff policies.Attends all required safety training programs and can describe his/her responsibilities related to general safety, department/service safety, specific job-related hazards, and national patient safety goals

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!

Baptist Health is an Equal Employment Opportunity employer.