PI​/Peer Review Coordinator - Improvement Non-Union, Exempt

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIES

• Communication:
  Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others. Demonstrates exceptional customer service and interacts effectively with physicians, staff, leaders, and the broader health care community.
• Decision-Making/Judgment:
  Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus, when possible, communicates decisions to others. Escalates issues that do not conform to established expectations to the Director. Maintains confidentiality and always protects sensitive data.
• Computer
  
  Skills:
  
  Skilled in the use of computers, adapts to new technology, keeps abreast of changes, learns new programs quickly, uses computers to improve productivity.
• Initiative:
  Searches out and communicates best performance and quality improvement practices. Identifies and recommends corrective action plans for implementation when indicator measurement is below target. Tackles problems and takes independent action, seeks out new responsibilities, acts on opportunities, generates new ideas, practices self-development. At least 50% of CEUs are related to performance improvement, patient safety and/or peer review subject matter.
• Interpersonal
  
  Skills:
  
  Has effective active listening skills, builds strong relationships, is flexible/open-minded, negotiates effectively, solicits performance feedback, and handles constructive criticism. Works collaboratively and supports efforts of team members. Collaborates effectively, efficiently, and appropriately with Medical Staff Leadership and members.
• Job Knowledge:
  Understands duties and responsibilities, has job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. Serves as a resource for standards of care and practice related to patient care and safety and staff safety. Maintains expertise in data definitions for external reporting. Identifies cases meeting the criteria for clinical case review.
  
  Performs RN level of retrospective morbidity and mortality review using indicators and screening criteria. Conducts detailed medical records reviews for peer review, as appropriate. Maintains knowledge of evidence-based, CMS/CDPH and Joint Commission clinical metrics (i.e., core measures, AHRQ Patient Safety Indicators, Hospital Acquired Conditions).
• Personal Organization:
  Keeps information organized and accessible, maintains clean/functional workspace, works systematically and efficiently, manages time well.
• Problem Solving/Analysis:
  Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. Meets with physicians, nursing and ancillary staff and leaders to determine the root cause/barrier to compliance and formulate performance improvement strategies. Considers age-specific and cultural issues in problem-solving case specific issues. Applies statistical tools to determine root causes of identified problems including flowcharts, trending forms, bar graphs and control charts.
  
  Understands statistical variation: common cause versus special cause and uses it to focus corrective actions.
• Productivity:
  Manages workload, prioritizes tasks, develops good work procedures, manages time well, handles information flow. Ensures needed data is collected on a timely basis and reports on progress are regularly distributed. Manages workload, prioritizes tasks, develops effective, efficient procedures that minimize waste. Ensures the timely reporting of required issues/items to both external agencies, the Peer Review Committee, Quality Committees, PI related Committees, and the Director or Manager of Quality/Performance Improvement.
• Project Management:
  Establishes project goals, milestones, and procedures, defines roles and responsibilities, acquires project resources, coordinates projects throughout company, monitors project progress, manages multiple projects. Participates in or coordinates multi-disciplinary PI teams to support key quality and patient safety initiatives. Supports or coordinates the following projects as assigned:
  Core Measures and related inter-rater reliability, reporting and improvement; peer review; mortality review, and other priorities as established in the annual PI and Patient Safety plans. Ensures the relevant findings, conclusions and recommendations resulting from the Peer Review system is reported as required.
• Quality:
  Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, recognizes and acts on quality problems. Data results are validated prior to…