Peer Review Program Administrator

Employment Type:

Full time

Shift:

Description:

Peer Review Program Administrator

Department: Medical Staff Office

Location: Trinity Health Livonia

Minimum rate of pay: $29.70

Shifts Available: Days

Status Available: Full-time, 40 hours/week

Total Rewards and Benefits:

• Competitive compensation, DAILYPAY
• Benefits effective Day One! No waiting periods.
• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-Term Disability
• Retirement savings plan with employer match and contributions
• Opportunity for growth and advancement throughout Trinity Health
• Tuition Reimbursement
  
  

Position Purpose:

The Peer Review Program Administrator (PRPA) is responsible for facilitation of the peer review and Professional Practice Evaluation (PPE) program, as well as related projects, of the organized medical staff to ensure ongoing practitioner competency, patient safety, engagement, and organizational compliance. Peer review activity and PPE are factored into the decision to maintain existing privileges, revise privileges, or revoke privileges prior to or at the time renewal. This role is responsible for department chair support with development, integration, and ongoing performance evaluation metrics, analytical and operational reporting (dashboards/scorecards), and ensuring departmental compliance with timely completion of reviews. This position develops detailed work plans, schedules, provides regular status reports and works with medical staff leadership to identify ongoing reporting needs to drive competency management systems. Provides expertise and education to hospital colleagues and medical staff on performance improvement strategies, methodology, tools, measurements, and documentation of outcomes. This position is an integral part of patient safety, quality assurance and performance improvement programming serving as a change agent to promote patient safety and practitioner engagement. Serves as a liaison between Medical Staff leadership and administration. Builds positive physician/practitioner relationships by actively engaging in dialogue, identifying areas of improvement, and working with leadership and other appropriate individuals to promote a culture of safety and engagement.

Required Qualifications:

Education:

• Bachelor’s degree in healthcare administration, information technology, nursing, or related field, or equivalent. Master’s degree in healthcare administration, information technology, nursing or related field preferred.
  
  

Experience:

• Minimum of 3 years of experience in healthcare, quality, peer review, or related role.
• Strong analytical and problem-solving skills to identify opportunities for improvement and problem resolution, to evaluate improvement procedures/techniques, analyze and interpret a variety of data into operational improvement.
• Excellent interpersonal, written, and verbal communication skills.
• Ability to facilitate multidisciplinary groups related to performance improvement.
• Leadership skills to direct and facilitate others towards objectives that contribute to the success of the organization.
• Organizational skills to effectively coordinate all aspects of the improvement program.
• Computer proficiency in PowerPoint, Word and Excel and experience navigating healthcare database systems.
• Midas/Statit proficiency preferred.
• Certification in Healthcare Quality (e.g., CPHQ) and/or training/certification in specific tools and techniques of performance improvement preferred.
• Experience creating dashboards and scorecards for executive level reporting preferred.
• Clinical experience/acumen preferred.
  
  

Physical and Mental Requirements and Working Conditions:

• Occasional to frequent clinical / patient facing work environment.
• Adapt to frequent interruptions, shifting priorities & stressful situations; must be able to show compassion and kindness, demonstrate patience.
• Work on a variety of tasks/projects in physical or virtual environments that may be stressful with individuals having diverse personalities and work styles.
• Relate to and work with ill, disabled, elderly, emotionally upset and at times hostile customers. Must possess the ability to deal tactfully with personnel, participants, family members, visitors, government agencies/personnel and the general public.
  
  

What you will do:

Peer Review Coordination:

• Develops, facilitates, and monitors processes and procedures that support peer review, Professional Practice Evaluation, and other essential processes to ensure the ongoing competency and quality of the medical staff.
• Manages, organizes, and coordinates the activities of the Medical Staff peer review program, including the direction and maintenance of a comprehensive and specialized peer review process.
• Coordinates and facilitates multidisciplinary teams/committees. Monitors outcomes related to real or potential events. Takes initiative to follow through on inquiries, problems, or requests.
• Assists with corrective action recommendations, including FPPE, external case review and letters of reprimand.
• Serves as a resource regarding medical staff peer review processes, procedures, and requirements. Follows, interprets, and assists with the development and enforcement of policies and procedures.
• Participates in the development and implementation of ongoing process improvement initiatives to drive performance improvement and ensure patient safety.
• Maintains confidentiality and ensures compliance with peer review policies and procedures.
  
  

PPE Management & Quality Improvement:

• Develop and implement processes for ongoing professional practice evaluation (OPPE), including development of metrics, building metrics, and coordinating metric integration. Monitors practitioner performance metrics and provide regular reports to leadership to identify opportunities for improvement.
• Ensure accuracy and completeness of OPPE data and documentation.
• Ensures compliance with focused professional practice evaluation (FPPE) requirements.
• Develop and maintain escalation procedures for non-compliance.
• Maintains and uses data and reports from systems to facilitate process improvement. Uses appropriate computer applications in data analysis and to facilitate data-based decisions.
• Collaborate with medical staff quality management teams to identify areas for improvement and implement best practices related to peer review and PPE.
  
  

Information Management & System Administration:

• Track and analyzes trends and outcomes of peer review and PPE processes.
• Works with physician leadership to develop metrics and strategies to improve performance.
• Maintain accurate records of peer review and OPPE activities for tracking and appropriate follow through; Maintains an accurate peer review data base; collecting, entering and interpreting data; Ensures profiles and subgroups are kept up to date and accurate.
• Maintains provider user accounts and control system access, scheduling reviews for new providers.
• Midas/Statit administrator/superuser and assists with training, education, and performance improvement to promote optimum efficiency. Trains Chairs, Service Chiefs, and local users how to use the OPPE system.
• Provide education and training to medical staff, medical staff leaders and committee members on peer review and OPPE requirements.
• Prepare reports for regulatory agencies, accreditation bodies, and internal stakeholders.
• Serves as part of the database support team.
  
  

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.