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  • The System Manager of Medical Staff Credentialing and Peer Review:

  • Provides system-wide direction and support to the hospitals, clinics, and other system services in the development of strategic and operational plans for upholding a highly reliable culture in patient safety and preventable harm reduction as well as continued awareness and knowledge of medical staff affairs and other provider-based regulatory requirements to include credentialing and peer review.

  • Continuously monitors financially incentivized quality programs to ensure maximizing benefit by reviewing and sharing metrics and areas of opportunity.

  • Holds responsibility for ensuring compliance with regulatory quality reporting programs and voluntary value based programs

  • Collaborates with cross-functional stakeholders and leaders in process-redesign to decrease variation and improve adherence to nationally recognized best practices to generate excellence in provider care delivery -partners with executive leaders, administrators, physicians, nursing departments and other staff in the management of reported safety events and peer review processes to also include provider-related occurrence report management, Root Cause Analysis, Healthcare Cause Mapping, and Human Factors Analyses

  • Consults for internal training programs and ongoing curriculum to support highly functioning teams who incorporate safety behaviors -Maintains high competence in the use of and distribution of quality and safety analytics platforms and databases to keep the organization informed of trends, performance, and opportunities for improvement

  • Manages the performance of and contributes to the success of staff who carry out Credentialing, OPPE, FPPE, Peer Review, MIPS, APMs, and other performance-based, financially-incentivized programs to be in full compliance with all regulatory and certifying bodies



  • Required:

    • Bachelors degree in Nursing
  • Preferred:

    • Masters degree in Healthcare Related Field

  • Required:

    • Registered Nurse License

  • Preferred:

    • Healthcare Accreditation Certificated Professional, Certified Healthcare Operations Professional, Certified Professional in Healthcare Quality

  • Required:

    • 4 years clinical healthcare delivery
  • systems design and process improvement

  • stakeholder-group management and communication

  • presenting to large and small groups successfully

  • measuring and monitoring key performance indicators and national quality indicators, and sharing metrics at the appropriate medical staff and other provider meetings

  • supervising staff in the credentialing, ongoing professional practice evaluation (OPPE), focused professional practice evaluation (FPPE), and peer review

  • regulatory compliance and enforcement

  • policy review, editing, drafting, and enforcing

  • Preferred:



    • Knowledge of Healthcare Medical Staff affairs, privileging, credentialing, OPPE, FPPE, and provider peer review
  • Knowledge of Quality Management System standards and principles included in ISO 9001

  • Knowledge of Accreditation, Certification, and other Survey Processes

  • Knowledge of CMS conditions of participation

  • Knowledge of Hospital Acquired Condition Reduction Program, Value Based Purchasing, and other pay for performance programs related to quality and safety of care

  • Knowledge of performance and workforce management practices and processes


    • Skills in reliably using ethical and business code of conduct standards
  • Skills in fostering a just culture using tools and evidenced-based strategies for peer review

  • Skills in translating patient safety events into meaningful information and communication to all types of providers

  • Skills in creative, technical, and academic writing

  • Skills in data analytics and business intelligence platforms Skills in process-oriented auditing and problem solving

  • Skills in developing and meeting key milestones and deadlines

  • Skills in coordinating, executing, and sharing results of nationally recognized Safety Culture Surveys

  • Skills in coaching, mentoring, supervising and advising subordinates


    • Ability to maintain adaptability and flexibility in meeting the needs of leadership, staff and subordinates for trends in provider practice and delivery
  • Ability to maintain confidentiality of information

  • Ability to maintain a non-judgmental, support-filled atmosphere while holding individuals accountable in keeping patients safe

  • Ability to implement and deploy complex plans using continuous quality improvement methodologies

  • Ability to prepare dashboards to be presented at board, executive, system-leader, provider, and staff meetings and events

  • Ability to plan for and conduct board, executive, leadership and staff meetings, retreats, summits, and educational offerings

  • Ability to risk-prioritize and quickly identify opportunities for improvement to maintain and improve patient safety and organizational well-being

  • Ability to optimize and maximize financial incentives for Merit Based Incentive Payment Model, and other Advanced Alternative Payment Models (APM), as well as private payer contracts where performance is financially incentivized

  • Ability to translate safety culture survey results into actionable plans that create a top decile safety culture in consultation with the medical staff and other provider leadership

  • Ability to create learning objectives and educate successfully using adult learning principles

  • Ability to efficiently and reliably store event information and peer review information in a complex healthcare system

  • Ability to encourage and foster high performance in subordinates to meet system strategic priorities and goals

  • Ability to leverage quality analytical platforms to inform self and others regarding quality and pay for performance based program scores



  • 50% Time Spent:

Designing and overseeing the execution of processes for Credentialing, OPPE, FPPE, Peer Review, MIPS, APMs and other performance-based, financially-incentivized programs to be in full compliance with Accreditation, CMS, other certifying and regulatory bodies, and the Medical Staff Bylaws and policies

  • 20% Time Spent:

Providing system-wide consultation and supporting the Medical Staff leadership and other provider-based groups in obtaining trended analytical information and benchmarks from quality platforms and databases for formal presentations and provider-centric recurring meetings.

  • 10% Time Spent:

Evaluating and monitoring the workflows and processes within the scope of this position and working with staff and other leaders to achieve reliable, quality output to keep providers, staff and the organization informed.

  • 10% Time Spent:

Managing the performance of subordinates to ensure the organizational mission, vision, values, and culture of excellence are upheld consistently.