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Job Description

Business Unit: Rush Medical Center

Hospital: Rush University Medical Center

Department: Medical Staff Office

**Work Type:** Full Time (Total FTE between 0.9 and 1.0)

**Shift:** Shift 1

**Work Schedule:** 8 Hr (8:00:00 AM - 4:30:00 AM) - First 90 days, in person. After 90 days, it would be hybrid.

Rush offers exceptional rewards and benefits learn more at our Rush benefits page (https://www.rush.edu/rush-careers/employee-benefits).

**Pay Range:** $66,560 - 108,326

Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush’s anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.

Summary:

The Medical Staff Quality & Performance Specialist provides process coordination and applies data analytics knowledge to assure that the Professional Practice evaluation process is effective and accurate in evaluating issues related to professional credentialing, conduct and practice. The Medical Staff Quality & Performance Specialist is responsible for collecting data, quality control of information, and statistical analysis of data for use in the OPPE/FPPE process. They will collect and analyze data, interpret results, and submit reports and recommendations to the leadership team as well as interpret results against set benchmarks following analysis and corresponding reports. The individual who holds this position must exemplify the Rush mission, vision, and values and acts in accordance with Rush policies and procedures.

Requirements:

+ Bachelor’s degree. Focus in Healthcare and/or healthcare quality analytics preferred.

+ Four (4) years of experience coordinating and monitoring quality and performance, preferably in an acute care (hospital) setting.

+ Experience with Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) programs strongly preferred.

+ Advanced Excel skills required.

Preferred **Requirements:**

+ Current NAMSS CPCS and/or CPMSM certification preferred.

+ Knowledge of patient care best practices.

+ Skills in evaluating cases and determining correct processes and training others to ensure maximum effectiveness.

+ Ability to read, analyze, and interpret medical periodicals, professional journals, technical procedures, or governmental regulations.

+ Ability to write reports, business correspondence, and procedure manuals.

+ Ability to effectively present information and respond to inquiries or complaints from leaders, committees, employees and physicians, in a timely fashion.

+ Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs; ability to apply basic algebraic concepts.

+ Ability to define problems, collect data, establish facts, and draw valid conclusions and clearly and concisely communicate status and results to leadership; ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

+ Ability to recognize areas of need, recommend and implement strategies for improvement.

Responsibilities:

+ Under the direction of Director/Manager, coordinates the professional practice evaluation process which includes the review of and analysis of medical records, data collection, and aggregation/analysis.

+ Organizes and analyzes clinical and administrative data from multiple internal and external sources and synthesizes results into meaningful reports and presentation. Performs complex quality analysis utilizing benchmark data from various sources, as appropriate.

+ Applies data analytics knowledge to screening criteria to identify cases requiring further analysis through assessment of information from various data systems. Collaborates with other analytic teams to research data discrepancies and validate data for accuracy. Coordinates and communicates with Director/Manager and Credentials Committee to assure consistent screening and presentation of cases for professional practice evaluation.

+ Coordinates and monitors professional practice evaluation initiatives for initial appointments, new privileges and for concern.

+ Oversees the preparation and coordination of the Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) clinical and professional metrics and collaborates with appropriate Departments and leaders for activities related to professional conduct and practice evaluation.

+ Oversees that peer review data is entered in appropriate database in a timely and accurate manner.

+ Generates associated data reports for designated Medical Staff committees and leadership.

+ Manages data quality and integrity based on defined standards through systematic audits.

+ Maintains knowledge of The Joint Commission and Centers for Medicare and Medicaid Services standards and requirements pertaining to the professional practice processes and professionalism.

+ Maintains a working knowledge Medical Staff Bylaws, Rules and Regulations, Credentialing Policy and other professional staff policies.

+ Documents all steps of the professional conduct and practice evaluation process including minutes and letter generation, tracking action items, action plan follow-up and resolution.

+ Utilizes discretion and maintains confidential, sensitive provider professional practice information; uses appropriate safeguards to prevent inappropriate use or disclosure of confidential peer review information.

+ Functions as an agent of the protected peer review process.

+ Assists the credentialing staff with the interpretation of privilege requests and case logs, when needed.

+ Monitors appropriate privileging requirements of care delivered by practitioners.

+ Adheres to organizational and department-specific safety standards and guidelines. Adheres to organization values of integrity, diversity, accountability, compassion, and teamwork.

+ Performs related duties as assigned.

Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.

**Position** Medical Staff Quality & Performance Specialist

**Location** US:IL:Chicago

**Req ID** 20070