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Physician Performance Quality Analyst

Company: Martin Memorial Health Systems, Inc.
Location: Stuart
Posted on: June 6, 2021

Job Description:

Together we create peace of mind through exceptional, personalized, compassionate care, always. If this speaks to you, then Martin Health has a place for you.

The Physician Performance Quality Analyst is responsible for assisting in the coordination of physician professional practice evaluation process. 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. Duties include comprehensive quality review of the medical record, abstraction, documentation in the Hospital's quality data base and review and analysis of clinical indicators related to practitioner medical management and practice patterns.

  • 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. Entry of case summaries into the Hospital's quality data base with ongoing monitoring and trending of the quality of patient care related to practitioner care. Responsible for generating a summary sheet from the Hospital;s quality data base for review by the Chairperson of the Peer Review and the Credentialing 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/Service 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 mailing a Practitioner Performance Report biannually 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 Microsoft Office to document data.

  • 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.

  • 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.

  • Runs 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.

  • 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.

  • Reviews I-Reports and enters findings into Verge database.

  • Performs chart reviews for peer review and disruptive behavior. Collects data for OPPE/FPPE.

  • Review, track and trend mortality cases, return to surgery cases, radiology, pathology, robotics, anesthesia, TeamHealth reports, HIM non-compliance, surgical PA line placement, blood management/utilization, and ED.

  • Review cases for requests on/from credentials, bariatric committee, insurance review of physician quality files, corporate compliance, and legal.

  • Provides new provider orientation as needed.

To effectively fulfill the requirements of this position, candidate must meet the following requirements:

  • Bachelor's Degree with a Major in Nursing, preferred;

  • Current/Active State of FL RN License required - primary source online verification required directly from State of Florida Licensing database;

  • Experience in an acute general hospital setting required.

Strong organizational, analytical and computer skills required. Ability to act independently and exercise initiative is essential. Possess excellent oral, written and interpersonal communication skills.

Keywords: Martin Memorial Health Systems, Inc., Palm Beach , Physician Performance Quality Analyst, Other , Stuart, Florida

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