Start the day excited to make a difference...end the day knowing you did. Come join our team.

Essential Functions & Responsibilities:

• Collaborates with appropriate physician leaders and other departments involved in data collection to identify and implement medical staff performance measures.
• Designs and implements an information management system that supports management of practitioner-specific performance data including trend analysis and peer review conclusions, in collaboration with the Information Services Department
• Works in collaboration with the credentialing staff to establish processes, data collection methods, and documents to support integration of performance data into the following professional review activities: provisional/focused reviews for initial appointment and extension of privilege(s) and re-appointment review processes.
• Provides leadership for the design, implementation, generation, and dissemination of practitioner-specific performance feedback reports/profiles.
• Performs clinical reviews in accordance with defined procedures and/or directions of medical staff leaders in a timely manner forwarding cases for physician level review, performing follow-up, when appropriate referring issues related to operations to an appropriate leader, and entering data into the medical staff quality database.
• Provides support to the Chair, Physician Quality Management Committee including development of policies and procedures related to professional practice reviews, report preparation, and meeting coordination.
• Designs and implements methods to achieve compliance with accreditation, licensure, and regulatory requirements pertaining to peer review in collaboration with the Director and appropriate medical staff leader(s).
• Assists the Director with the budget preparation and department leadership relevant to the Performance Improvement Analyst's scope of responsibilities.
• Performs other duties as assigned.

Qualifications:

• Valid RN License from Virginia or reciprocal compact state
• Minimum of ten (10) years prior healthcare quality related work experience required (quality/utilization management, performance improvement, case management, risk management).
• Bachelor's Degree preferred and will be considered in lieu of minimum experience.
• Certified Professional Healthcare Quality (CPHQ) preferred.
• Prior work experience in the following disciplines preferred: medical staff quality/peer review, healthcare quality, performance improvement, risk management, and utilization/case management.
• Knowledge of Joint Commission and CMS standards pertaining to credentialing, ongoing and focused professional practice review (peer review), and performance improvement.
• Knowledge and work experience involving clinical data abstraction, data presentation, and statistics.
• Proficient in basic office information systems (Microsoft Office preferred), Internet skills, and data base management.
• Prefer prior experience with MIDAS or other quality/peer review information system.
• Requires strong organizational, time management, oral and written communication skills.
• Detail oriented with ability to interpret applicable regulatory requirements and apply knowledge to promote compliance.
• Recognize and maturely handle a variety of problems and situations, often of a confidential or urgent nature.
• Ability to preserve confidentiality despite pressure from physicians and outsiders.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.