Quality Peer Review (RN-Medical Staff Office)

Job Description

Responsibilities

Medical Peer Review Coordinator(RN) – Medical Staff Office

Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273-bed acute care facility providing quality healthcare to the residents of Aiken and surrounding communities. Aiken Regional Medical Centers has been ranked a top hospital in South Carolina by the Carolina Center for Medical Excellence for its treatment of heart attack, heart failure and pneumonia. Services provided at the hospital include emergency medical care, orthopedic surgeries, maternity, and behavioral health services.

Job Duties :

• Facilitates, as necessary, concurrent peer review process with the department manager and physician chair or designee.
• Prepares a summary report of concurrent review conclusions for presentation to MPRC
• Coordinates with Medical Records for data / record retrieval for retrospective peer review process.
• Maintains up-to-date knowledge of issue being reviewed in order to facilitate accuracy and appropriateness of review.
• Coordinates meeting location, dates, times, and committee member notification for each scheduled meeting.
• Prepares committee agenda with chairperson to facilitate organized review of peer review issues.
• Coordinates attendance of other associates as per the discretion of MPRC.
• Performs Level I Medical Peer Reviews, documents summary of case review
• Collaborates with MPR chair for assignment of physician reviewer for level II review
• Facilitates completion of oppe / FPPEs as recommended.
• Maintains documentation of Peer Review Activities
• Responsible for the maintenance of all initiated peer review forms in a manner that most facilitates an organized MPRC.
• Maintains all information from MPRC meetings in a confidential manner.
• Records minutes of MPRC meetings.
• Facilitates the referral of issues to the appropriate physicians, clinical, administrative, and ancillary areas for implementation of necessary improvements / recommendations of MPRC.
• Assists with the development of criteria that can be used to monitor and evaluate patient care objectives.
• Delegates and / or participates in chart reviews for the collection / analyzing of data for process improvement opportunities.
• Generates regular report for the MEC describing activities and findings of MPRC, to be presented by committee chairperson.
• Coordinates with Medical Staff Office for flow of information / reporting of peer review results to the MEC
• Enters all referrals for Medical Staff Peer Review into MIDAS.
• Follows-up on all MPRC referrals to involved physicians to ensure timely response to requests / recommendations, to be reported at MPRC.
• Coordinates follow-up of any referrals made to medical staff, clinical, ancillary, or administrative departments.
• Follows-up on all MPRC referrals to other departments for monitoring implementation of any improvements or policy / procedure changes.
• Compiles all follow-up documentation for reporting back to MPRC for further determination / conclusion.
• Provides education as needed for departmental monitoring and implementation of MPRC recommendations.
• Provides education to medical staff as needed regarding peer review process, performance improvement methodology, or Joint Commission accreditation guidelines.
• Trends medical staff involvement in peer review activities and provides report to Physician Services.
• Trends occurrences of identified quality / risk issues for the purpose of identifying opportunities for process improvement.
• Facilitates external peer review for specialized reviews when applicable.
• Recognizes trends and other opportunities for process improvement, and initiates follow-up as necessary.
• Creates reports and otherwise provides database statistics and information as requested.
• Coordinates resolution of integration issues between applications.
• Serves as a resource to others where knowledge and skills are helpful.
• Maintains and utilizes computer skills to track and trend quarterly indicator measurements for benchmarking performance data about processes and clinical outcomes with other hospitals.
• Facilitates training and application of comparative database and quality software systems.
• Collects, complies, analyzes, interprets and reports data on clinical metrics to appropriate committees and individuals to achieve compliance with organizational and department goals by trending the collected and clinical practice data.
• Uses clinical databases and national benchmarking to continuously identify opportunities for improved outcomes through the utilization of best practice and current resources.
• Performs concurrent Core Measure medical record reviews and communicates with staff and physicians regarding recognized opportunities.
• Provides inter rater reliability for in house abstraction.
• Participates in achieving departmental goals and quality efficient patient care.
• Participation in occasional travel to attend educational opportunities or other hospital related activities.
• Responsible for coordination of policy approval through appropriate committees.
• Collaborates with Medical Staff Coordinator to facilitate OPPE / FPPE.

Benefits for Aiken Regional employees include :

About Universal Health Service

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $13.4 billion in 2022. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has 94,000 employees continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the , Puerto Rico and the United Kingdom.

Qualifications

Education requirements : Degree in accredited Registered Nursing Program; BSN required.

Work experience requirements : Minimum of 3 – 5 years in an acute care setting, with comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services, and intervention techniques; also familiar with performance improvement strategies and Joint Commission standards.

Required licenses / certifications / courses Current SC or compact state license

Required skills, knowledge and abilities : Must have excellent interpersonal skills in order to interact effectively with all disciplines; must be highly organized and detail-oriented; must have basic computer kills and an understanding of data analysis.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Salary : $13