Education and Work Experience:

• Bachelor's Degree in Nursing (BSN): Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of practice: Required

Essential Functions:

• Assists in the design and modification of Peer Review monitors, focus studies, and other Quality Improvement activities with special emphasis on data sources, data collection tools, data input, data acquisition, analysis, and presentation format. Collaborates with the Medical Staff Coordinator in preparing Case Review agendas, notification letters to attributing physicians to attend Case Review meeting discussions or correspondence regarding closure status of their cases, and ensures accuracy of all minutes pertaining to case review.
• Establishes and maintains policies & procedures and processes for identifying and tracking the clinical performance and/or unprofessional conduct issues that warrant peer review. Verifies conformity of recommendation to case review findings and may assist in the assigning process of reviews to appropriate reviewers. Coordinates and facilitates case reviews at the Multidisciplinary Case Review and Perinatal Case Review Committees.
• Supports and coordinates Peer Review activities to ensure all peer review activity is appropriately documented and recorded for use in the Quality Assessment Performance Improvement program. Coordinates the activities of the medical staff to ensure the relevant findings, conclusions and recommendations resulting from the Peer Review System are reported as required. Supports Risk Management program by researching all peer review cases referred to Risk Management Program through the occurrence review process.
• Designs, conducts, and evaluates studies and problem focused reviews requested by the leadership executives, medical staff, risk manager or department director. Assists in the preparation of the reports and may develop and conduct presentations on the peer review quality improvement standards to insure compliance with regulatory agency standards. Identifies educational opportunities and issues which require follow-up from chart review.
• Collaborates in hospital Risk Management program by researching all peer review cases referred to quality management (QM) through the occurrence review process. Collaborates with decision support to prepare the list of patients who meet the CHART criteria. Collaborates with department managers and other supervisory personnel in the solving of problems and addressing issues of concerns identified. Collaborates with the Infection Preventions by sharing potential opportunities for improvement regarding documentation of central line and ventilator care.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.