Medical Staff Clinical Quality Specialist

Peer Review Coordinator

Coordinate all aspects of the clinical peer review process, including case identification, data collection, physician referrals, and follow-up activities. Prepare peer review cases for committee evaluation and physician review. Track ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) activities. Monitor action plans, corrective measures, and case resolutions.

Organize and support medical staff quality committees and peer review meetings. Prepare meeting agendas, minutes, reports, and supporting documentation. Maintain confidential committee records and peer review files. Ensure compliance with bylaws, policies, and confidentiality requirements.

Assist with compliance related to medical staff quality in accordance with The Joint Commission, Centers for Medicare & Medicaid Services, state and federal healthcare regulations. Support accreditation surveys and audits. Maintain documentation required for credentialing and quality reporting. Provide Provider education to support medical staff compliance with regulatory standards to promote high-quality care.

Collect, analyze, and maintain peer review and quality improvement data. Generate reports, dashboards, and trend analyses for leadership and committees. Monitor physician quality indicators and outcomes. Maintain databases related to provider performance and peer review activities.

Serve as liaison between physicians, medical staff leadership, quality departments, and hospital administration. Communicate peer review requests and follow-up requirements professionally and confidentially. Assist providers with peer review documentation and process questions.

Collaborate with the Quality, Patient Safety and Professional Excellence department to ensure alignment with medical staff regulatory standards, and related hospital priorities. Effectively manages assigned projects with a level of independence in performance of the role to include problem resolution. Attends required hospital-wide orientations, meetings, and in-services. Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest trends in field of expertise. Other duties as assigned.

Bachelor of Science in Nursing (BSN) preferred. Active Registered Nurse (RN) licensure preferred for clinical peer review oversight roles. Degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field. Minimum of 25 years of experience in medical staff services, clinical quality improvement, peer review coordination, risk management, hospital administration, acute care hospital experience strongly preferred. Experience working with physicians, medical staff leadership, and accreditation standards.

Knowledge of medical staff bylaws, peer review processes, OPPE/FPPE standards, healthcare quality improvement methodologies, accreditation and regulatory standards. Strong organizational and analytical skills. Excellent written and verbal communication. Ability to maintain strict confidentiality. Proficiency with electronic medical records (EMR), credentialing software, Microsoft Office Suite. Ability to maintain strict confidentiality and handle sensitive provider information.

Certified Professional Medical Services Management (CPMSM), Certified Professional in Healthcare Quality (CPHQ).

Hospital or healthcare system administration office. Interaction with physicians, nursing leadership, and quality management teams. Primarily sedentary office work with frequent computer use. Ability to attend/lead meetings outside standard business hours.

We are an E-Verify employer. For more information, please refer to the E-Verify Participation Poster and E-Verify Right to Work Poster.

Nashville General Hospital at Meharry