Registered Nurse - Facility Peer Review Coordinator - Full Time Days - Ocala at AdventHealth

Date Posted: 10/25/2020

Job Snapshot

  • Job Schedule
  • Location:
    Ocala, FL
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
  • Shift
    1 - Day

Job Description

Facility Peer Review Program Coordinator AdventHealth Ocala

Location Address: 1500 SW 1st Ave Ocala, Florida 34471

Top Reasons To Work At AdventHealth Ocala
  • Horse Capital of the World
  • Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota

  • Part of the community since 1898, providing healthcare to Marion County for over 120 years

  • Florida Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited

  • Spectacular springs throughout the county
Work Hours/Shift:
Full Time/ Days
You Will Be Responsible For:
  • Utilizing critical thinking skills and medical knowledge of clinical care guidelines to review and analyze the appropriateness of practitioner medical management on the basis of established quality indicators with associated thresholds/goals and national clinical care guidelines based on best practice recommendations.
  • Performs professional and objective medical record review of cases to determine appropriateness of patient care based on evidence-based outcomes and clinical guidelines approved by the medical staff. Responsible for generating a summary sheet from the designated Quality data resources for review by the Chairperson of the Peer Review and the Credentialing and Governance Committees. 
  • Collects, aggregates, and displays data as requested for Peer Review meetings, and other medical staff quality committees and meetings.
  • Duties may include assisting Department Chairman/Chiefs and Peer Review Physician Reviewers in their review of a case by providing support documentation and resources such as current Policies and Procedures, Medical Staff Bylaws and Rules and Regulations.
  • Facilitating, coordinating and performing physician performance evaluations (ongoing and focused) in accordance with the Joint Commission requirements. Responsibilities include generating (and available upon request) a Practitioner Performance Report at appropriately defined intervals that details the practitioner's performance related to quality of care indicators with established acceptable thresholds and goals. 
  • Coordinate and facilitate various quality meetings relating to practitioner performance. Collaborates with Department Chairman, Chief Medical Officer and Physician Peer Review Chairman to identify process deficits, trends and/or practice patterns. 
  • Document minutes for various meetings, compose and send correspondence related to practitioner quality issues and utilize appropriate software applications to document data. 
  • Attends department and committee meetings as required. Responsibilities may include preparation of agenda and materials for presentation.
  • Collaborate with practitioners to provide explanation regarding quality issues, and outcomes reported via quality department dashboards, and performance reports.
  • Assists in timely submission of Quality/Peer Review data to the Patient Safety Organization.
  • Collaborates closely with the Risk Management Department regarding the recognition, research, isolation and resolution of potential problems.
  • Supports and assists the Quality Management Resources associates to obtain documents and assemble medical staff credential quality files, when requested.
  • Works collaboratively with a wide range of healthcare professionals including providers, other healthcare leaders and medical records personnel.
  • Requests reports from the Quality Data Resources for Peer Review Committee and Credentialing Committee meetings, in addition to individual Practitioner requests and organizational requests.
  • Provides education regarding quality expectations, regulatory requirements, Ongoing Professional Practice Evaluation, Focused Professional Practice Evaluation and Policy and Procedures to onboarding practitioners.
  • Continually assesses and improves upon the tools and mechanisms for which information is gathered for FPPE/OPPE activities including indicator selection and application.
  • Performs duties and responsibilities as requested.
  • Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
  • Assist as required with coordination and preparation in anticipation of Joint Commission surveys and respond appropriately during survey activity. Assist with the development and implementation of plans of action for any and all applicable survey findings.
  • Utilizes superior discretion and ability to maintain confidential sensitive Physician Peer Review information. Uses appropriate safeguards to prevent inappropriate use or disclosure of confidential case review information.
  • Complies with established corporate and departmental policies, procedures, objectives, quality assurance methods, and safety codes. Demonstrates compliance with licensing, regulatory and accrediting agency provisions as required.
  • Other duties as assigned

What You Will Need:

  • Bachelor of Science in Nursing (BSN)

  • Minimum five (5) + years’ experience in an acute care setting

  • Active Board of Nursing License, Florida

  • Six Sigma Yellow Belt Certification; or have begun education towards certification within one (1) year.


Job Summary:

The Facility Peer Review Program Coordinator is responsible for managing the coordination of the physician professional practice evaluation process. Duties include comprehensive quality review of the medical record, abstraction, appropriate and accurate documentation of findings and review and analysis of clinical indicators related to practitioner medical management and practice patterns. This position supports medical staff initial practitioner credentialing and re-credentialing process and enhances compliance with The Joint Commission requirements for Focused Professional Practice Evaluation (FPPE) and Ongoing Physician Performance Evaluation (OPPE) standards by assisting the OPPE/FPPE coordinators when necessary. This position will also provide onboard training and education to Medical Staff when indicated.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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