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Data Integrity * Implementation and responsibility for the development and management of Medical Staff Peer Review programs and oversight of all Medical Staff Performance Programs including, FPPE and OPPE processes. * Provides comprehensive medical record review of referrals for analysis of standard of care. * Works directly with the Medical Staff Peer Review committees at Northern Arizona Healthcare in reporting, reviewing and follow-up of cases sent to committee for review assuring peer review process is functional and improves the quality of care by the medical staff. * Identifies trends in provider behavior and quality of care. * Oversight of Medical Staff peer review meetings including preparation, minutes and follow-up. * Ensures data integrity, collection, validation, trending, and reporting to MEC as required. |
People Management/ Staff Development * Coordinate with the Medical Staff Performance Improvement Coordinator & Clinical Analyst to support the effectiveness of the NAH Medical Staff Performance Program. * Maintains knowledge of all standards and regulations involving medical staff performance data and peer review. * * Create learning opportunities that advance Medical Staff Leadership and Medical Staff Services team. |
Performance Management * Works closely with Medical Staff leadership and Performance Improvement Coordinator and Clinical Analyst to ensure effectiveness of Performance Improvement Program * Ensures effective roles and processes are developed within the department to support the Performance Improvement Program. * Assists with limited Director duties in Directors absence. |
Department Management * Responsible for searching external databases and web sites to keep current on all data benchmarks and using data abstraction tools to produce meaningful analyses and correlation of data. * Maintains proficiency in the use of MDStaff, MIDAS, MDStat, Stat-it and other databases as necessary. |
Compliance/Safety * Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner. * Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. * Completes all company mandatory modules and required job-specific training in the specified time frame. |
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