Job Description
Start the day excited to make a difference…end the day knowing you did. Come join our team.
Job Summary:
The Senior Performance Improvement (PI) Analyst is responsible for developing, implementing, and maintaining performance improvement processes related to medical staff peer reviews, credentialing, and regulatory compliance. This role collaborates with physicians, hospital leadership, and quality teams to enhance patient safety, improve clinical outcomes, and ensure adherence to accreditation and regulatory standards. The Senior Analyst will utilize data analytics, process improvement methodologies, and stakeholder engagement to drive performance excellence and accountability within the medical staff.
Essential Functions and Responsibilities:
Medical Staff Performance & Peer Review Process Management
- Develops, implements, and oversees the Professional Practice Evaluation Program ensuring alignment with medical staff bylaws, The Joint Commission (TJC), CMS, and other regulatory requirements.
- Collaborates with Process Improvement Nurse (PIN) to ensure Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes are enforced, thus ensuring compliance with accreditation requirements.
- Collaborates with physician leaders and credentialing staff to integrate performance data into appointment, privileging, and reappointment processes.
- Establishes criteria for practitioner-specific performance measures, ensuring timely and objective peer reviews that foster constructive feedback and improvement.
- Supports the Physician Quality Management Committee with policy development, report preparation, and coordination of peer review activities.
Data Analytics & Performance Reporting
- Designs and implements an information management system for practitioner-specific performance data, including trend analysis and peer review conclusions, in collaboration with the Information Services Department.
- Analyzes physician performance data, clinical outcomes, and peer review findings to identify trends, patterns, and areas for improvement.
- Develops dashboards, scorecards, and detailed performance reports to track progress and compliance with peer review processes.
- Maintains databases and records related to physician performance and quality improvement.
Regulatory Compliance & Accreditation Readiness
- Ensures peer review processes comply with all accreditations, licensure, and regulatory standards, including TJC, CMS, and state health department regulations.
- Serves as a subject matter expert during audits, surveys, and compliance reviews related to physician performance and peer review activities.
- Collaborates with risk management, medical staff services, and quality teams to ensure ongoing accreditation readiness and process improvements.
Education, Training & Stakeholder Engagement
- Conducts training sessions, workshops, and individualized coaching for physicians and medical staff on FPPR processes, objectives, and best practices.
- Develops educational materials such as guidelines, toolkits, and FAQs to support peer review engagement and continuous learning.
- Provides expert guidance to medical staff and leadership on performance improvement methodologies and patient safety principles.
Process Improvement & Stakeholder Collaboration
- Leads interdisciplinary committees and workgroups focused on performance improvement initiatives.
- Process improvement methodologies to enhance efficiency and effectiveness of peer review workflows.
- Collaborates with IT, medical staff leadership, and quality teams to optimize peer review processes and technology integration.
- Facilitates discussions with physicians, hospital leadership, and administrative teams to ensure ongoing feedback and engagement in performance improvement efforts.
- Attends the Medical Staff Department and/or division meetings.
Administrative & Leadership Support
- Assists department leadership with budget preparation and projects related to performance improvement initiatives.
- Supports strategic planning efforts related to quality, performance review, and medical staff improvement.
- Leads the team and provides guidance and mentorship to colleagues.
- Performs other duties as assigned.
Qualifications:
- Registered Nurse (RN) with an active, unencumbered license required.
- Bachelor’s degree in healthcare administration, Nursing, Public Health, or a related field required; Master’s degree in healthcare administration, Quality Improvement, or related discipline preferred.
- A minimum of five years of clinical nurse experience required; with at least two years in quality, performance improvement, or risk management in a healthcare setting, and/or quality management or performance improvement experience preferred.
- Proficiency in data analysis tools (Excel, Tableau, Power BI) and medical staff credentialing systems (Credentialing Stream, MD-Staff, Cactus, or similar), and work experience involving clinical data abstraction, data presentation, and statistics required.
- In-depth knowledge of The Joint Commission (TJC), CMS, and medical staff performance review standards required.
- Experience in hospital operations, accreditation readiness, or physician performance review and medical staff quality, healthcare quality, performance improvement, risk management, and utilization/case management preferred.
- Proficiency with MIDAS, Quality Management, Credential Streams (Verity) Software, EPIC, Electric Medical Record (EMR) and Verge Safe Report System preferred.
- Certified Professional Healthcare Quality (CPHQ) preferred.
- Occasional travel to different hospital sites or clinics may be required.
As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.
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