MLK Community Hospital & Foundation
1680 E. 120th St.
United States of America
If you are interested please apply online and send your resume to NOrozco@mlkch.org
Act as a leader and internal consultant to medical staff committees regarding peer review, specialty specific studies and performance improvement activities. Collaborates with physicians in determining peer review indicators, what quality measures to study, developing appropriate study designs and data collection tools, appropriate data collation, analysis and summarization. The responsibility also includes facilitating discussions and providing appropriate and ongoing feedback and follow-up to ensure sustained improvements. Communicates results to all stakeholders. Assures compliance with Joint Commission standards and CMS Conditions of Participation. This position may require flexibility of hours.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Facilitates the peer review process by ensuring regular review and approval of peer review indicators. Assists in educating new physician leaders of the process for revising and approving peer review indicators. Liaison for the Quality Department and supports elected/appointed physician leaders in their role(s).
Coordinates and facilitates the peer review process by evaluating occurrence reports, patient complaints, telephone referrals, direct referrals and custom reports.
Identifies the appropriate peer review indicator, reviews the chart, and completes the case summaries for the peer review meetings. Ensure case summaries completed timely for physician’s initial review and determination. Updates the case summaries after each and every review capturing the discussions and conclusions accurately. Coordinates with the medical staff coordinator for appropriate flow of cases as it moves forward and back.
Coordinates with the Chair of Professional Practice Review Committee the need for data collection, trending and analysis of certain events or indicators related to physician performance.
Supports the credentialing process by accurately reflecting the case assignations and timely completion of peer review activities.
Collects and organizes approve4d data for tracking, trending and benchmarking; incorporating appropriate data interpretation and analytical techniques to support peer review and performance improvement activities of the medical staff.
Provides data back to appropriate parties, presenting any relevant analysis.
Supports the facility’s risk management process, infection control surveillance process and performance improvement process by providing information derived from medical records review.
Contributes to successful reaccreditation, relicensure and recertification of the facility by participating in survey readiness including data collection of measures of success (MOS).
Maintains accurate information in the peer review database. Tracks all performance improvement activities, continuing medical education and systems improvement.
Consultant to physicians and other staff regarding peer review policy and procedures.
Other duties as assigned.
- BSN required. Master’s degree preferred.
- Current CA RN license required.
C. Special Skills/Knowledge
- 5+ years’ experience in an acute care setting. Critical Care or ED experience preferred. Peer review experience preferred.
- Excellent communication skills and evidence of collaborative practice
- Proficient in email, Excel and internet programs
- Ability to collaborate in a team environment and produce positive outcomes by motivating others