Job Overview:This position works collaboratively with the Medical Staff Department / Section Chairs, Service Line System Chiefs, and Nursing leadership in the development and support of quality initiatives to improve patient outcomes. Facilitates peer review of clinical performance within QA Committees and initiates further activity to support Medical Staff and improve care delivery. Identifies and evaluates patient care issues using applied knowledge, clinical experience, and analytical skills. Works in collaboration with physician / practitioner and nursing leadership to implement Professional Practice Evaluation to meet Joint Commission accreditation compliance requirements of providers. Supports root cause analysis, apparent cause analysis and other applicable Patient Safety activities.Job Requirements:Bachelor's Degree in Nursing or Bachelor's Degree in Health Administration, other related fieldRegistered NurseCurrent Ohio licensureCardiopulmonary Resuscitation (CPR)Basic Life SupportKnowledge in field of specialtyKnowledge of quality assessment, quality improvement techniques, i.e., medical chart reviewExcellent communication and customer service skills Experience in Data Analysis and Statistical Reporting3-4 years experience Clinical in Nursing in specialty area of patient care relevant to the assignment and other extensive clinical, medical/surgical, or critical care experience3-4 years experience Nursing in Quality Improvement and Medical Peer Review in a Healthcare settingJob Responsibilities:Collaborates with Medical Staff to perform physician peer review including FPPE and OPPE reviews in strict accordance with the established guidelines (TH and Joint Commission). Identifies trends and utilizes a proactive approach in notifying all Chairs for further follow-up and direction. Provides a summary incorporating assessment and analysis of FPPE findings and initiates appropriate corrective action. Reviews and evaluates patients' medical records and applies quality measures/criteria and utilizes hospital approved tools. Screens cases using clinical expertise and recommends referral for organized physician peer review. Provides necessary and appropriate follow through.Formally prepares and presents quality narrative and statistical reports in a clear and objective format for the Medical and Administrative Staff (as required). Analyzes and validates quality outcome data and reports trends by practitioner, service line, or procedure. Proficiantly uses data systems, and skills with applications such as Excel, Word, and PowerPoint, and effective report development.Acts as staff and/or participating member of various Specialty Quality Committees; responsibilities may include agenda planning/meeting organization, coordinating follow-up as directed, and assisting in the development of methods/tools and/or process for implementing projects/programs that have the potential to positively impact the quality of patient care.Organizes and staffs all assigned clinical quality measures. Assists with the implementation of policies and procedures for the quality assurance and improvement function of TriHealth and assures compliance with The Joint Commission and other accrediting agencies and regulatory bodies. Facilitates commitment to an organization-wide quality structure and strategies for process improvement. This includes process development, data analysis and report preparation from the following databases: The Joint Commission/Centers for Medicaid and Medicare Services Core Measures, American College of Cardiology, Society of Thoracic Surgeons, Health Data Management, and Premier Clinical Advisor.Works collaboratively with other healthcare providers and ancillary services as part of the Healthcare Team to provide the necessary effective measurement and analysis of the patient care services received. Effectively communicates and responds to re