We are Emerus, the leader in small-format hospitals. We partner with respected and like-minded health systems who share our mission: To provide the care patients need, in the neighborhoods they live, by teams they trust. Our growing number of amazing partners includes Allegheny Health Network, Ascension, Baptist Health System, Baylor Scott & White Health, ChristianaCare, Dignity Health St. Rose Dominican, The Hospitals of Providence, INTEGRIS Health, MultiCare and WellSpan. Our innovative hospitals are fully accredited and provide highly individualized care. Emerus' commitment to patient care extends far beyond the confines of societal norms. We believe that every individual who walks through our doors deserves compassionate, comprehensive care, regardless of their background, identity, or circumstances. We are committed to fostering a work environment focused on teamwork that celebrates diversity, promotes equity and ensures equal access to information, development and opportunity for all of our Healthcare Pros.

The purpose of this position is to lead, implement and oversee a comprehensive Medical Staff quality program, with a focus on peer review, performance evaluation, and cross-departmental collaboration. This role plays a critical part in ensuring physician accountability, improving patient safety, and enhancing the flow of quality data across the system.

• Assist with creation and maintenance of scorecards for ongoing and focused professional practice evaluations (OPPE/FPPE) for medical staff.
• Assist in reviewing scorecard data to identify performance issues.
• Conducts peer review activities including case review, documentation, committee presentation, and follow-up on recommended actions.
• Collaborates with Quality, Risk, Medical Directors to address physician performance and safety concerns.
• Works in collaboration with the Patient Safety Organization on enhancing physician processes to improve patient safety.
• Reviews and recommends improvements to peer review policies and procedures.
• Assists in the establishment and maintenance of a system-wide peer review committee to standardize processes and enhance oversight.
• Supports the implementation and continued use of a new peer review module, including training and workflow integration.
• Contributes to building a robust medical staff-centered quality program that ensure physician outliers are identified and addressed beyond the facility level.

• Attend staff meetings or other company sponsored or mandated meetings as required
• Perform additional duties as assigned
• Ability to work off-hours and on call when required

• An unencumbered and current license as a Registered Nurse (RN) in one of the US states, required.
• 2+ years of clinical experience as an RN, required.
• Previous experience in peer review, case management, quality oversight, clinician education or similar, required.
• Bachelor of Science in Nursing, required.
  • Master of Science in Nursing or higher in related field, preferred.
• Strong knowledge of accreditation standards with DNV, state, federal laws, required.
• Comprehensive knowledge of medical staff office functions and responsibilities, required.
• Knowledge of medical-legal issues, peer review protections, and awareness of the legal ramifications of hospital documentation and compliance deficiencies, required.
• Strong proficiency with Microsoft Office (Excel, Word, PowerPoint and Outlook), required.
• Position requires fluency in English and extensive knowledge of medical terminology and technology; written and oral communication.
• Experience with RL Datix system, preferred.