Medical Staff Clinical Quality Specialist
Nashville General Hospital · Nashville, TN · 2 wk ago
On-siteHealthcareFull-time
Key Responsibilities
- Celebrate Peer Review Coordination:
- Cover all aspects of the clinical peer review process, including case identification, data collection, physician referrals, and follow-up activities.
- Prepare peer review cases for committee evaluation and physician review.
- Track ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) activities.
- Monitor action plans, corrective measures, and case resolutions.
- Cover all aspects of the clinical peer review process, including case identification, data collection, physician referrals, and follow-up activities.
- Committee & Medical Staff Support:
- Organize and support medical staff quality committees and peer review meetings.
- Prepare meeting agendas, minutes, reports, and supporting documentation.
- Maintain confidential committee records and peer review files.
- Ensure compliance with bylaws, policies, and confidentiality requirements.
- Organize and support medical staff quality committees and peer review meetings.
- Regulatory & Accreditation Compliance:
- Aid in compliance related to medical staff quality in accordance with:The Joint CommissionCenters for Medicare & Medicaid ServicesState and federal healthcare regulations
- Support accreditation surveys and audits.
- Maintain documentation required for credentialing and quality reporting.
- Aid in compliance related to medical staff quality in accordance with:The Joint CommissionCenters for Medicare & Medicaid ServicesState and federal healthcare regulations
- Data Management & Reporting:
- Collect, analyze, and maintain peer review and quality improvement data.
- Generate reports, dashboards, and trend analyses for leadership and committees.
- Monitor physician quality indicators and outcomes.
- Maintain databases related to provider performance and peer review activities.
- Collect, analyze, and maintain peer review and quality improvement data.
- Communication & Collaboration:
- Serve as liaison between physicians, medical staff leadership, quality departments, and hospital administration.
- Communicate peer review requests and follow-up requirements professionally and confidentially.
- Absorb provider education to support medical staff compliance with regulatory standards to promote high-quality care.
- Serve as liaison between physicians, medical staff leadership, quality departments, and hospital administration.
Qualifications
- Education: Bachelor of Science in Nursing (BSN) preferred; Active Registered Nurse (RN) licensure preferred for clinical peer review oversight roles.
- Experience: Minimum of 2–5 years of experience in: Medical staff services Clinical quality improvement Peer review coordination Risk management Hospital administration Acute care hospital experience strongly preferred.
- Knowledge & Skills: Knowledge of:Medical staff bylawsPeer review processesOPPE/FPPE standardsHealthcare quality improvement methodologiesAccreditation and regulatory standards Strong organizational and analytical skills Excellent written and verbal communication Ability to maintain strict confidentiality Proficiency with:Electronic medical records (EMR)Credentialing softwareMicrosoft Office Suite Excellent analytical, organizational, and communication skills. Ability to maintain strict confidentiality and handle sensitive provider information.
- Preferred Certifications: Certified Professional Medical Services Management (CPMSM) Certified Professional in Healthcare Quality (CPHQ)