At St. Luke’s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally.

What You Can Expect

This role manages multiple team members, medical staff committees and medical staff issues.

• Responsible for the coordination of all operational aspects of the department, including organizing and conducting programs and establishing procedures for medical staff peer review functions across the health system.
• Liaison and resource for medical staff peer review committees and the committee chairs across the St. Luke's Health System for peer review process compliance, external peer review, peer review indicator selection and maintenance, ongoing professional practice evaluation.
• Provides leadership, guidance, counseling and continuing education pertinent to peer review to staff.  Selects, develops, coaches, mentors, and assesses performance of staff.  Works with staff to promote resolution of conflict and counsels staff when standards are not met.
• Update and maintain systems (database management, event reporting tools to record activities of peer review including follow-up as well as ongoing professional practice evaluation report data gathering and generation of the reports.)
• Evaluates effectiveness of all medical staff peer review programs across the system, analyzes trends and implements changes as required.
• Utilizing data and observation, identifies problems and potential solutions to ensure department efficiency.
• Ensures accreditation compliance with regulatory organizations.
• Leads performance improvement initiatives within the Medical Staff Performance Improvement Department.
• Makes recommendations and develops policies and procedures for the area of oversight.
• Provides input and leadership in budget planning, implementation, monitoring, and efficiency.

Qualifications

• Education: Bachelors' Degree Nursing
• Licenses/Certifications: Current RN licensure from the State of Practice; CPHQ certification and/or lean sigma certificate/training preferred.
• Experience: Minimum of 5 year's experience in healthcare setting preferably in a leadership or management role related to medical staff services or peer review processes.  Experience in conducting peer reviews, quality assurance, and performance improvement initiatives within a medical staff context is beneficial.

Knowledge and Skills

• Strong understanding of medical staff governance, accreditation standards (e.g., Joint Commission, NCQA), and regulatory requirements related to peer review processes.
• Familiarity with healthcare quality metrics, data analysis, and reporting.
• Excellent organizational and project management skills, with the ability to manage multiple priorities and deadlines.
• Proficiency in using electronic health records (EHR) systems and healthcare data management software.

• Exceptional verbal and written communication skills, with the ability to effectively interact with diverse stakeholders, including physicians, administrative staff, and regulatory bodies.

• Ability to build and maintain positive relationships with medical staff, fostering a culture of collaboration and continuous improvement.

• Strong conflict resolution and negotiation skills, with a focus on maintaining professionalism and confidentiality.

• Demonstrated leadership capabilities, with experience in mentoring and developing team members within a healthcare environment.

• Ability to influence and drive change in a clinical setting, promoting best practices and adherence to peer review processes.

• A strong commitment to improving patient care quality and safety through effective peer review processes.

• Knowledge of current trends and best practices in peer review and quality improvement in healthcare settings.

At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Virgin Pulse Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.