Peer Review and Professional Practice Evaluation Coordinator (RN)

Welcome to Montage Health’s application process!

Job Description

The Peer Review and Professional Practice Evaluation Coordinator is responsible for coordinating and supporting the hospital’s physician peer review, Ongoing Professional Practice Evaluation (OPPE), and Focused Professional Practice Evaluation (FPPE) processes for credentialed and privileged providers. This role ensures provider performance evaluation activities are conducted in a timely, consistent, confidential, and compliant manner in accordance with Medical Staff Bylaws, applicable policies, The Joint Commission standards, CMS Conditions of Participation, and state regulatory requirements.

This position facilitates the professional practice evaluation lifecycle by reviewing and summarizing clinical information, coordinating peer review activities, tracking OPPE and FPPE requirements, preparing reports for medical staff leaders and committees, and maintaining accurate documentation in credentialing, privileging, quality, and peer review systems. The Coordinator works collaboratively with medical staff leadership, department chairs, peer reviewers, Quality, Risk Management, Medical Staff Services, and other stakeholders to support patient safety, quality improvement, and regulatory readiness.

This position reports directly to the Manager of Medical Staff Services and works in close collaboration with the Director of Quality on physician performance evaluation, peer review, patient safety, and quality improvement initiatives.

This position requires onsite presence for a minimum of one week per month. Onsite requirements are subject to change based on organizational, departmental, operational, regulatory, or patient care needs.

Principal Accountabilities

• Coordinates physician peer review activities, including case intake, tracking, committee preparation, follow-up, and documentation.
• Reviews, analyzes, and summarizes medical records and clinical events for use in the peer review and professional practice evaluation process.
• Assists in the development, implementation, and ongoing evaluation of meaningful OPPE metrics and reports to support the assessment of provider competence and the delivery of safe, high-quality patient care.
• Prepares and maintains OPPE and FPPE reports, provider quality profiles, dashboards, tracking logs, and summary documents for medical staff leaders and committees.
• Coordinates peer review committee meetings by preparing agendas, compiling case materials, documenting committee findings and recommendations, distributing follow-up communications, and tracking assigned action items.
• Maintains timely and accurate entry of peer review, OPPE, and FPPE data in credentialing, privileging, quality, or peer review software systems.
• Maintains current knowledge of Medical Staff Bylaws, Rules and Regulations, policies, The Joint Commission standards, CMS requirements, and other applicable state and federal regulations related to peer review and professional practice evaluation.
• Collaborates with department chairs, medical staff leaders, Quality, Risk Management, Information Technology, and Medical Staff Services to collect, validate, analyze, interpret, and report provider performance data.
• Tracks cases referred for peer review from quality reports, patient complaints, clinical indicators, adverse events, department referrals, or other approved sources.
• Analyzes provider performance data and identifies trends, patterns, opportunities for improvement, and potential concerns requiring further review.
• Supports organizational readiness for accreditation surveys and regulatory reviews by maintaining complete, accurate, and readily retrievable peer review and professional practice evaluation documentation.
• Provides education, guidance, and support to providers, medical staff leaders, and internal stakeholders regarding OPPE, FPPE, and peer review processes.
• Supports policy and procedure development related to professional practice evaluation and contributes to ongoing process improvement.
• Strong written and verbal communication skills, including the ability to prepare clear summaries, reports, minutes, and committee materials.
• Adheres to all organizational policies, procedures, safety standards, privacy requirements, and confidentiality expectations.
• Completes required training, in-services, continuing education, and competencies within established timeframes.
• Maintains professional communication and collaboration with providers, leaders, colleagues, and interdisciplinary partners.
• Supports a culture of quality, patient safety, accountability, and continuous improvement.
• Performs other related duties as assigned.

Knowledge, Skills, and Abilities

• Demonstrated ability to maintain confidentiality and discretion regarding sensitive provider performance and peer review information.
• Strong analytical skills with the ability to identify trends, documentation gaps, and opportunities for process improvement.
• Excellent written and verbal communication skills.
• Strong organizational, project management, and time-management skills.
• Ability to prioritize multiple competing deadlines.
• Ability to work independently and collaboratively with interdisciplinary teams.

Additional Preferred Experience

• Experience supporting Medical Staff Services, credentialing, privileging, physician peer review, or healthcare quality.
• Experience with OPPE/FPPE program administration.
• Experience using credentialing, quality management, or peer review software.
• Knowledge of accreditation standards, including The Joint Commission and CMS Conditions of Participation.

Education

Bachelor's degree in Nursing (BSN) preferred. Associate degree in Nursing with relevant experience may be considered.

Licenses and Certifications

Current, active, and unrestricted California Registered Nurse license required.

Equal Opportunity Employer

#LI-AC1

Assigned Work Hours

Full time

Position Type

Regular

Pay Range (based on years of applicable experience):

$73.91

to

$98.85

The hours employees work determine when a shift differential is paid.

Hourly Evening Shift Differential: $5.50

Hourly Night Shift Differential: $8.00