Professional Practice Evaluation Coordinator - Quality & Safety Management

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.

USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

JOB PURPOSE:  Manages the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) for all practitioners privileged through the Medical Staff Process. Leads Medical Staff Leadership in determining department quality indicators. Assures clinical appraisal and hospital activity components of medical staff credentialing process are complete for completion of initial FPPE and OPPE at reappointment. The professional responsibility within their scope of practice includes:Abide by and enforce all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values; Adheres to policies pertaining to confidentiality;Have regular and prompt attendance; Ability to work the assigned schedule including overtime and call as required; Utilization of proper body mechanics when: Moving equipment or supplies that are necessary to perform essential functions; The department responsibilities include: Requires minimal supervision to oversee the Medical Staff Focus Professional Practitioner Evaluation (FPPE) and Ongoing Professional Practitioner Evaluation (OPPE) processes; Manage the Focused Professional Practice Evaluation (FPPE) Process; Work closely with Medical Staff Coordinator's to identify all providers who are requesting new privileges;Initiate the FPPE process on all new initial applicants, re-applicants requesting additional clinical privileges, and for any provider in need of a triggered review; Educates providers under a FPPE as well as Department Chairs, Section Chiefs and Medical Staff Leaders and assessors of the FPPE process as needed.; Review case lists of new providers to clinically determine which cases are appropriate for review by Medical Staff Leadership.; Hold Medical Staff Leadership accountable to complete reviews, in order to remove provider from FPPE.; Submits completed FPPE to Department Chair/designee accountable for completion of evaluation and signature to remove practitioner from FPPE.; Prepares and present FPPE reports for the Combined Credentialing Committee and the Medical Executive Committee.; Manage the policy process and execution of the OPPE program under the general supervision and guidance of the Manager of Medical Staff Services and Chief Medical Officer.;Ensure OPPE profiles and subgroups are kept up-to-date and accurate.; Oversee the OPPE custom metric upload process into the external database; Track specific custom metrics related to internal metrics (i.e. professional conduct reports, etc.); Prepare and analyze OPPE reports; Perform initial clinical assessment of all OPPE reports for Medical Staff Leadership; Collaborate with various departments for development, building, and coordination of quality metrics utilized for OPPE; Influence Medical Staff Leadership by identifying outliers within their respective department and facilitate 'next steps' to evaluate or drive improvement in individual provider performance; Collaborates with the Department Chair/Section Chief in analyzing data to assess for trends, performance improvement opportunities and strengths and makes recommendations as it pertains to the OPPE program; File FPPE and OPPE reports and any pertinent paperwork in each provider’s electronic credential file. Guide the Medical Staff in interpretation of data, making recommendations and taking action; Coordinate focus studies and researching medical literature when necessary to evaluate quality of care; Prepare and communicate revisions to Medical Staff Bylaws, Rules and Regulations, Policies, Guidelines and plans as it relates to Medical Staff Quality Improvement; Provide OPPE/FPPE education to medical staff and advanced practice professionals, department Chairs, medical staff committees, medical staff office personnel, and others as needed; Assist Department Chairs in the revision of privilege checklist when needed; Maintains current knowledge of Joint Commission/CMS standards related to Medical Staff Credentialing Focus Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE);The communication responsibilities include: Communicates and uses appropriate customer relation skills with physicians, patients, families and co-workers in person and via telephone;Responds to email, calls and text messages in a timely manner; The documentation responsibilities include:Maintains accurate, complete and confidential information utilized in the Medical Staff QA program; The citizenship responsibilities include: Accepting and completing all duties positively and without conflict; Cooperating, helping others and improving the performance of the QM department; Completing all mandatory department, educational and hospital requirements; Utilizing cost effective practices in performing all aspects of the job; Adheres to current Infection Control and Safety standards; The responsibilities for providing age specific care include: This position is not age sensitive; The responsibilities for unit/departmental specific include: Serves as a member of various committees as directed; Advise department chairpersons in planning, monitoring, and evaluation activities; Uses internet, e-mail, databases, spreadsheets and word processing programs; At least intermediate proficiency skills with Excel, Word, PPT, Outlook (graphs, pivot table, slicing, presentation and data display, effective use of Outlook tools, etc.); Experience with multiple databases and ability to easily learn new databases/programs; Requires standing and walking for extensive periods of time; Adheres to policies pertaining to confidentiality; regular and prompt attendance; ability to work schedule as defined and additional hours as required; related duties as required.  

Bachelor’s degree in nursing from an accredited institution as approved and accepted by the University of South Alabama, four years of acute care hospital experience, and current Alabama RN license or current Multi-State RN License in accordance with Nurse Licensure Compact (NLC) for Alabama. Master’s degree is preferred and will substitute for one year of the required experience. Medical Staff Credentialing and Focus Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) experience and data collection analysis and presentation abilities are preferred. Extensive knowledge of CMS and TJC standards pertinent to medical staff policies and procedures, and other state regulatory rules and regulations are preferred.

Note: USA Health abides by the NLC requirements and guidelines for the state of Alabama.

EO Employer – minorities/females/veterans/disabilities/sexual orientation/gender identity.