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Medical Staff Quality Coordinator -Daya

VCU Health
LOC100004 CMH Main Hospital, United States, United Statesfull_timeVerifiedPosted 15 Apr 2025

About the role

The Medical Staff Quality Coordinator plays a crucial role in ensuring the quality and compliance of medical staff activities within a healthcare facility. The Medical Staff Quality Coordinator facilitates processes such as peer review, development of physician KPIs (specialty measures for OPPE), file management, quality data collection for OPPE/FPPE, and preparation of cases for presentation and review by provider peer committees.

Monday - Friday Days

Essential Job Statements

  • Collects and analyzes data from medical records, patient complaints and grievances, and other sources to collect data for review and trending to meet requirements for provider OPPE and FPPE processes. 

  • Facilitates peer review activities including case review and performance evaluation of providers. 

  • Prepares for medical staff meetings, including scheduling, agenda preparation, and recording minutes  

  • Maintain confidential credential and peer review files on all medical staff members. 

  • Maintains medical staff quality files and participates in the regulatory review activities related to medical staff requirements. 

  • Collaborates with medical staff and Quality to identify, develop, and track and trend provider KPI’s to meet regulatory and quality requirements. 

  • Supports the collection of medical staff quality data for provider compensation payment. 

  • Participates in the work of serious safety event investigation and action planning. 

  • Provides on-boarding education to medical staff related to electronic peer review module use and peer review participation requirements. 

  • Coordinates with medical staff credentialing to plan and implement on-boarding activities and assure timely completion of the FPPE/OPPE processes. Ensure compliance with state and federal regulations, accreditation requirements, and hospital policies 

  • Plans, designs, implements, and maintains a comprehensive continuous quality improvement (CQI) program. 

  • Assists in educating new staff, including physicians, about quality improvement systems and requirements 

  • Collaborates with medical staff leadership to develop and implement quality improvement plans aligned with organizational goals and regulatory requirements.  

  • Facilitates the development of quality improvement projects across different medical specialties. 

  • Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the department.  Provides assistance to team members. Accepts alternate assignments, as required. 

Patient Population

Not applicable to this position. 

Employment Qualifications 


Required Education: 

Bachelor’s degree in healthcare administration, nursing,  or related field. 

Combination of education and experience may be considered in lieu of a degree.

Preferred Education: 

Licensure/Certification Required: 

Certification in Professional Medical Services Management (CPMSM) within 5 years of accepting position.

Licensure/Certification Preferred: 

Project Management certification. 

Minimum Qualifications 

Years and Type of Required Experience 

Two (2) years’ experience in an acute medical setting working with education, peer review, and/or quality improvement. 

Other Knowledge, Skills and Abilities Required: 

  • Strong communication and interpersonal skills to collaborate with diverse medical staff. 

  • Strong organizational skills. 

  • Proficiency in data management and reporting tools. 

  • Clinical knowledge and understanding of medical practice is preferred. 

  • Experience in, or willingness to learn, quality improvement methodologies and data analysis. 

  • Proficiency in use of Microsoft office programs including Excel, Word, PowerPoint. 

  • Knowledge of healthcare regulations and accreditation standards related to competencies and certification. 

Cultural Responsiveness

Other Knowledge, Skills and Abilities Preferred: 

N/A 

Working Conditions 

Periods of high stress and fluctuating workloads may occur.     

General office environment.     

Required to car travel to off-site locations, occasionally in adverse weather conditions.  

May have periods of constant interruptions.     

Prolonged periods of working alone.   

Physical Requirements   

Physical Demands: Lifting/ Carrying (0-50 lbs.), Push/ Pull (0-50 lbs.). Stoop, kneel, squat

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Company

VCU Health

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