Coordinator Peer Review Quality at YVMC in Steamboat Springs CO

Company: Yampa Valley Medical Center (YVMC)

Location: Steamboat Springs CO

Title: Coordinator – Peer Review and Quality

Application Web page:


  • Facilitates the gathering and review of key quality indicators for the purpose of ensuring strong quality outcomes and accountability to support the facility’s strategic plan and regulatory requirements.
  • Supports Medical Staff quality programs, including medical staff peer review, data gathering, reporting and review for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), as well as medical staff issues related to occurrence reports.
  • Duties include concurrent and retrospective chart review; and providing clinical intervention and education to staff and physicians regarding the outcomes of all of the above.
  • Supports an effective medical staff professional practice evaluation process that supports medical staff reappointment, advancement, and clinical quality.


  • Utilizing organizational and industry standard tools, will abstract, enter and report on required key data elements necessary for coordination of provider review and the collection of national quality indicators data. Maintains knowledge of Evidence-based, CMS and TJC clinical metrics (i.e. Core Measures, AHRQ Quality and Safety Indicators, Hospital Acquired Conditions).
  • Reviews daily census to assist with early identification of patients who meet indicators of triggers for peer review or meet quality and safety measure criteria to ensure metric compliance concurrently. Functions as a resource to provide clinical intervention, education and follow up to providers and appropriate department leaders regarding the peer review process.
  • Queries multiple databases for clinical, administrative, and peer review data. Conducts (RN) screening of cases in the data in a timely and objective manner in order to determine level of peer review needed. Communicates with HIM, Risk Management and Compliance to prepare medical records appropriately during the peer review process. Works collaboratively with the Chief Medical Officer, Medical Staff Medical Director, and Chair of Peer Review as needed to screen and approve cases for reciprocal or external review. Initiates sending of and receiving of all reviews and alerts providers of reports when received. Communicates committee dispositions to providers in a timely manner and according to policy. Works collaboratively with the Quality and Patient Safety Teams, appropriate clinical departments and teams to develop and implement plans for improvement as needed.
  • Assists the Quality Manager in the coordination of key quality and safety indicators throughout the YVMC system. The quality and safety measures can include, but are not limited to, the core measures created by CMS and The Joint Commission, measures to support the IPPS and OPPS programs of CMS, AHRQ safety and quality measures, Hospital Engagement/Hospital Improvement and Innovation Network measures, and quality measures created to support the strategic plan of YVMC. Coordination includes manual abstraction of measures, data collection and analysis, and interaction with key stakeholders that impact these measures.
  • Applies statistical principles to calculate appropriate summary measures and provides quarterly summary reports on Quality and provider review for administration and clinical leadership. Identifies and incorporates comparative benchmark practices into reporting. Coordinates with the facilitators of other quality committees (Trauma, Infection, Robotics etc.) to receive quality of care reports, assist with interpretation of data and presents that information routinely at appropriate meetings and committees as appropriate.
  • Performs routine and intensive medical record audits. Coordinates data for professional practice evaluation including abstracting, filing, and maintaining professional practice evaluation (PPE) log and tier three reviews. Assists the Chief Medical Officer, Chief of Staff, Department Chairs, and appropriate committees to identify process deficit trends and/or practice patterns.
  • Utilizes professional critical thinking skills and knowledge of clinical care guidelines and national priorities for care review. Accurately and completely documents and reports results of case review (clinical care as well as system or process issues) in a timely manner, compiles case summary, and refers to appropriate parties for follow up. Tracks cases to ensure timely resolution and follow up as appropriate.
  • Facilitates the Multi-disciplinary Professional Practice Evaluation Committee (PPEC, including preparing agenda, case review materials, minutes etc.). Participates in case discussions as appropriate for cases presented for committee review. Ensures appropriate communication and resolution of issues with all parties involved based on committee recommendation/ action. Maintains database of PPE activities. Ensures all appropriate documentation is copied to the corresponding quality file within Medical Staff Services.
  • Ensures compliance with applicable regulatory guidelines and requirements, State and Federal statutes, and Medical Staff Bylaws, Rules, and Policies. Must be HIPAA compliant. Utilizes superior discretion and ability to maintain the confidentiality of highly sensitive PPE information. Uses appropriate safeguards to prevent inappropriate use or disclosure of confidential case review information.
  • Actively participates in departmental performance improvement and survey readiness activities.
  • Performs other duties as assigned.


  • Education: Bachelor of Science in Nursing or health related field preferred.
  • Work Experience: 2 years of Quality Assurance/Performance Improvement experience highly desired with 5 years previous experience in acute care clinical setting necessary. Professional Practice Evaluation (Peer review) experience required.??Proficiency with electronic medical record systems required. Experience in project development, project management and strong analytical skills, including data entry, manipulation, management, and data analysis preferred.
  • Licenses/Certifications: CO Licensed Registered Nurse required. Certified Professional in Healthcare Quality preferred
  • Knowledge, Skills, Abilities: Proficient in Windows-based operating software (Microsoft Office) and systems.
  • Knowledge of patient quality, safety and satisfaction performance measures and indicators, data definitions and sources and relevant national databases and benchmarks; knowledge of healthcare quality, safety and satisfaction data design, collection, aggregation and summarization; and knowledge of performance improvement models, methods and systems strongly preferred. Excellent written and oral communication and presentation skills required. Must promote and demonstrate a logical, systematic and non-judgmental approach to case review with the ability to formulate concise and relevant summaries with competing factors. Solution driven with the ability to address difficult situations with tact and diplomacy
  • Ability to work under minimal supervision, ability to adapt quickly to changes within the work environment.
  • Ability to work with providers of all levels to coach and provide feedback on performance. Must be a team player and have proven success applying a collaborative and professional approach and ability to work in conjunction with physicians, clinical managers/directors, colleagues and customers in a supportive way to communicate sensitive information and troubleshoot issues.
  • Working Environment: Works in a temperature controlled environment with natural and artificial lighting.
  • Essential Physical Requirements Able to perform repetitive standing, sitting, stooping, walking, and reaching. Performs minimal lifting of 15 lbs, carrying 15 lbs, and reaching over head 10 lbs.

For more information and to apply vist YVMC job “Coordinator – Peer Review &
Quality” web page

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