Raleigh General Hospital Who We Are: People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Raleigh General Hospital is a 300 bed facility caring for nearly 13,000 patients each year with over 50,000 being treated in our emergency room. We offer a wide range of surgical services as well as specialty programs including Cardiac CTA, Digital Mammography, and Trauma Services. Where We Are: Beckley is an ideal place to live and boasts many scenic, cultural, and recreational opportunities. From restaurants and breweries to art galleries and unique attractions, Beckley is an outdoor playground with something for all tastes. Why Choose Us: · Health (Medical, Dental, Vision) and 401K Benefits for full-time employees · Competitive Paid Time Off / Extended Illness Bank package for full-time employees · Employee Assistance Program – mental, physical, and financial wellness assistance · Educational assistance and tuition assistance for qualified applicants · Professional development opportunities and CE assistance · And much more… JOB SUMMARY This position is responsible for administering the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) programs as well as coordinating the Peer Review Program in accordance with the medical staff bylaws at a system level to meet accreditation standards. This position will be responsible for preparing FPPE Scorecards at initial appointment, for additional privileges, or clinical/behavioral concerns, and OPPE Scorecards at reappointment. Develop processes to keep all applicable parties informed of trends and outcomes, capture all documentation requirements according to policy, and ensure timely communication. Responsible for managing the Clinical Professional Practice Evaluation (PPE) or Peer Review. Advance the Medical Staff peer review process in collaboration with the Medical Staff Leadership, Quality and Safety, and System Manager. ESSENTIAL FUNCTIONS Focused Professional Practice Evaluation (FPPE) activity • Initiates the FPPE process on all new initial applicants, re-applicants requesting additional clinical privileges, and for any provider in need of a triggered review. • Maintains FPPE reports in the electronic credentialing program. Keep accurate up to date FPPE log for each provider. • Analyzes data to assess trends, performance improvement opportunities and strengths and makes recommendations as it pertains to the OPPE program. • racks variances in required information and follows up on discrepancies and/or outstanding forms/plans, etc., ensuring deadlines are met. • Educates providers under a FPPE as well as Department Chairs, Section Chiefs and Medical Staff Leaders and assessors of the FPPE process as needed. • Submits completed FPPE to Department Chair for evaluation and signature. Forwards information to the Credentials/Interdisciplinary Practice Committee, Medical Executive Committee and Board of Director's for final approval. • Forwards notification of approval for release from FPPE to the provider via a letter from the Board of Director's. Ongoing Professional Practice Evaluation (OPPE) activity • Coordinates the policy process and execution of the OPPE program under the general supervision and guidance of the Manager of Medical Staff Services and Chief Medical Officer. • Collaborates with Department Chairs and Section Chiefs to develop specialty specific indicators/measures, to align with OPPE standards and Hospital operations and system capabilities. Periodically reviews measures to assess feasibility, appropriateness, and achievement. • Coordinates retrieval of indicator data with Quality Department through various Hospital sources, • Collaborates with the Department Chair/Section Chief in analyzing data to assess for trends, performance improvement opportunities and strengths and makes recommendations as it pertains to the OPPE program. • Copies, distributes, and files OPPE reports and any pertinent OPPE paperwork in each provider's credential file. • In coordination with the Manager of Medical Staff Services and Chief Medical Officer, follows up with medical staff leaders, medical staff services staff and providers to keep the OPPE process and documentation current and proceeding as necessary to meet deadlines and reporting requirements. Peer Review activity • Collaborate and coordinate with the Peer Review Nurse to support an effective and continuously improving medical staff peer review program. • Maintains information in a secure file for timely retrieval. • Prepare reports for any trends, and for evaluation at time of reappointment or when requested by Department Chair, Section Chief or Medical Staff Leaders. • Ensure timely communication of findings are made to providers. • Meets department standards and turnaround times for volume of work processed and accuracy of data entered. • Maintains minutes of all peer review meetings. • Keeps abreast of accreditation standards in relation to FPPE, OPPE and peer review. Educate medical staff leaders, medical staff services staff and providers, fostering a commitment to compliance to these programs throughout the hospital. Knowledge, Skills and Abilities • Demonstrates sound judgment, patience, and maintains a professional demeanor at all times • Exercises tact, discretion, sensitivity, and maintains confidentiality • Performs essential job functions successfully in a busy and stressful environment • Learns current and new computer applications and office equipment utilized at Bozeman Health • Strong interpersonal, verbal, and written communication skills • Analyzes, organizes, and prioritizes work while meeting multiple deadlines JOB REQUIREMENTS Minimum Education Required -Bachelor's degree in Nursing, Healthcare or related field Preferred -Master's degree in Nursing, Healthcare, or related field Required Skills • Must have computer skills and dexterity required for data entry and retrieval of patient information. • Must be proficient with Windows-style applications and keyboard. • Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals throughout the patient care process • Work independently and set abstraction priorities based on regulatory guidelines. • Knowledge of regulatory and accrediting standards • General knowledge and understanding of the principles and theories of quality management and continuous quality improvement Minimum Work Experience Required -5 years experience working as a professional in a healthcare environment. EEOC Statement: Raleigh General Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law. **Job:** **Quality* **Organization:** **Raleigh General Hospital* **Title:** *FPPE/OPPE Coordinator-PRN* **Location:** *West Virginia-Beckley* **Requisition ID:** *7418-12232*