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Coordinator, Medical Staff Quality Assurance

Company University of South Alabama
Location Mobile, AL 36688
Update 4 Day ago
Essential Functions Oversees the Medical Staff Quality Assurance (MSQA) program; coordinates the Combined Credentialing Committee activities to include agenda, minutes, meeting notices, privilege check sheets updates approval and FPPE quality reports; attends all medical staff Morbidity & Mortality/Peer Review Committee meetings to provide performance improvement data and capture peer review discussion; coordinates the medical staff monthly reports that are submitted to the Medical Executive Committee meetings; coordinates the medical staff document processes for Ongoing Professional Practice Evaluation (OPPE) and FPPE; assists the medical staff with data analysis and utilization of their Crimson Continuum of Care and Vizient data for performance improvement and engagement of quality cost-effective patient care; coordinates the Medical Staff QA data for all physician reappointments, and provides QA data upon request; attends all Rapid Response Committee meetings and coordinates physician related issues, i.e., referrals; coordinates Focus Professional Practice Evaluation (FPPE) reviews related to practice concerns that involve chart monitoring and trending/analysis of data; serves as a liaison between the Crimson Physician Champion and the Chairs, medical staff members and medical staff residents; acts as a Performance Improvement (PI) facilitator for the PDSA PI improvement model; presents educational lectures at the medical staff department meetings on performance improvement activities as needed; assists with the chart review, staff interviews and Root Cause Analysis team meetings for adverse and near miss events; coordinates patient concerns/issues related to physicians with the Patient Representative Supervisor; performs CMS Core Quality Measure abstractions based on special departmental necessities; maintains Crimson Continuum of Care and Vizient database and ensures software updates and report developments are current; communicates and uses appropriate customer relation skills with physicians, patients, families and coworkers in person and via telephone; responds to overhead pages; maintains accurate, complete and confidential information utilized in the MSQA program and hospital Performance Improvement program; accepts and completes all duties positively and without conflict; plans, collects, organizes and reports QA data for peer review/physician credentialing, external and internal benchmarking programs according to the hospital's PI plan; serves as liaison with Risk Management, medical staff leaders and Patient Safety Officer in relaying potential risk issues as indicated; maintains current knowledge of Joint Commission/CMS standards; serves as a member of various committees as directed; advises department chairpersons in planning monitoring and evaluation activities; provides education regarding Joint Commission and Performance Improvement to various healthcare audiences; abides by and enforces all hospital policies and compliance requirements, including those pertaining to confidentiality; adheres to current Infection Control and Safety standards; communicates with physicians, patients, families, and the healthcare team in person and via the telephone; responds to overhead pages; accesses and accurately maintains electronic and paper medical records; regular and prompt attendance and the ability to work schedule as defined and overtime and call as required; related duties as required.

Minimum Requirements Bachelor's degree in nursing or allied health from an accredited institution as approved and accepted by the University of South Alabama, four years of directly related experience, and current licensure with the state of Alabama in clinical field. Master's degree is preferred and will substitute for one year of the required experience. Hospital performance improvement experience, healthcare research, or data collection analysis and presentation are preferred. Experience with MS Excel, Word, Power Point, Outlook (graphs, pivot table, slicing, presentation and data display). Experience with multiple databases and ability to learn new databases/programs.

Working Days and Hours Monday - Friday
8:00 a.m. - 4:30 p.m.

The University provides benefits to eligible University of South Alabama and USA HealthCare Management LLC, employees based on employment status - regular or temporary - and position FTE (hours worked per week), length of service, and other criteria. Refer to specific benefit plans for information regarding eligibility and coverage for eligible dependents. Several of the University's benefit programs require staff to enroll within a specified period of time or wait to make changes until the annual open enrollment period.

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