MEDICAL STAFF RN QUALITY COORDINATOR (REQ 3923)

The Medical Staff RN Quality Coordinator is responsible for overseeing and supporting the quality and performance improvement efforts of the medical staff at South Peninsula Hospital. The role ensures compliance with accreditation and regulatory standards, facilitates peer review and assists with provider credentialing processes, and collaborates with medical staff leadership to enhance patient safety and clinical outcomes.

POSITION HIGHLIGHTS & RESPONSIBILITIES

Quality and Performance Improvement:

• Develop, implement, and monitor quality improvement initiatives related to medical staff performance.
• Analyze clinical and operational data to identify trends, variances, and opportunities for improvement.
• Work closely with physicians, advanced practice providers, and hospital leadership to develop and implement evidence-based best practices.
• Participates in root cause analysis (RCA) for adverse events involving medical staff.

Regulatory Compliance & Accreditation:

• Ensure compliance with CMS and state regulatory standards, and any applicable certifying or accrediting bodies related to medical staff quality and credentialing.
• Prepare reports and documentation for regulatory audits, accreditation surveys, and quality assessments.
• Maintain knowledge of evolving regulatory requirements and provide education to medical staff on compliance updates.

Medical Staff Peer Review & Credentialing Support:

• Assist in coordinating the peer review process, including case reviews, provider evaluations, attending meetings and performance improvement plans.
• Support the Peer Review Committee, Medical Executive Committee (MEC) and other hospital committees in reviewing provider performance and ensuring adherence to bylaws, policies, and standards.
• Collaborate with the Medical Staff Office (MSO) to ensure efficient credentialing, privileging, and ongoing professional practice evaluation (OPPE/FPPE).

Education & Collaboration:

• Provide education and training on quality metrics, evidence-based practices, and regulatory compliance to medical staff.
• Serve as a liaison between medical staff, nursing, and hospital administration to promote interdisciplinary collaboration on quality initiatives.
• Participate in hospital-wide performance improvement projects and committees.

EDUCATION & EXPERIENCE

Education & Experience:

• Required: Registered Nurse (RN) with an active state license
• Preferred: Bachelors or Master’s degree in Nursing (BSN/MSN), Healthcare Administration, or related field.
• Minimum 3-5 years of clinical nursing experience (preferably in acute care or quality improvement).
• Experience in quality management, medical staff services, education or regulatory compliance is highly desirable.

Skills & Competencies:

• Strong knowledge of hospital quality programs, accreditation standards, and peer review processes.
• Experience with data collection, analysis, and reporting for quality improvement initiatives.
• Proficiency in electronic medical records (EMR), quality reporting software, and credentialing databases.
• Excellent communication, leadership, and interpersonal skills to collaborate with physicians and healthcare teams.
• Ability to manage multiple projects, work independently, and meet deadlines in a dynamic healthcare environment.

ENVIRONMENT:

South Peninsula Hospital is a 22 bed critical access hospital (CAH) with a 28 bed long term care facility and 9 bed Emergency department that operates 24 hours per day. The hospital is located on the southern end of the Kenai Peninsula.  At South Peninsula Hospital, we are more than just a hospital. We are the community’s leading healthcare organization, offering not only the services expected in a small town, like primary care, home health and a nursing home, but also more advanced specialty services, like orthopedics, interventional radiology, pediatric therapy and neurology. And thanks to our outstanding staff, we are a three-time top 100 critical access hospital and score above the state and national average in the Medicare Hospital Compare patient satisfaction and quality scores and Press Ganey Employee Satisfaction Survey. SPH recently obtained a 5 Star Patient Satisfaction rating through CMS (Centers of Medicare & Medicaid Services).

Homer, Alaska, is a small, charming seaside community nestled on the shores of beautiful Kachemak Bay, offering breathtaking views of glaciers, mountains and wildlife. You’ll be impressed with the surrounding school, museums, art galleries, fine dining options and seaside accommodations. If you are looking for community, adventure, culture, scenery or solitude, you'll find all of that and more here!