Peer Review Program Manager

Position Details

Department : CORP | Medical Staff Services

Location : Phoenix

Shift : Mon-Fri, Days, 8am-4pm

Category : Prog Coord / Mgr

Posting # : 935177

Employee Type : Full-Time

Position Summary

The Medical Staff Quality manager is responsible for overseeing the collection, management, and analysis of provider performance data, including Ongoing Professional Practice Evaluation (OPPE) and protected case review data. This role ensures that peer review committee cases move efficiently through various phases of evaluation while maintaining compliance with regulatory and accreditation standards. The Peer Review manager collaborates with medical staff leadership, quality improvement teams, and hospital administration to promote patient safety and provider accountability.

Position Duties

• General

Reviews, analyzes and summarizes medical records for use in the Provider Peer Review

Process.

Attends Physician Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further provider review, and report results back to referring committee.

Oversees that provider peer review data is entered into the Integrated Credentialing Management Program in a timely and accurate manner.

Assists with preparation of quarterly peer review reports that are reported up to appropriate

system committees.

Maintains knowledge of the hospital Medical Staff Bylaws, Rules and Regulations and

policies.

Provides support and assistance to other hospital departments as necessary to facilitate the physician peer review process by coordinating cases referred for physician peer review.

Ensures safe care to patients, staff and visitors; adheres to all PCH policies, procedures,

and standards.

Collect, analyze, and report Ongoing Professional Practice Evaluation (OPPE) and Focused

Professional Practice Evaluation (FPPE) data.

Ensure compliance with DNV, and other accrediting body requirements.

Work with department chairs and medical staff leadership to review performance metrics

and recommend action plans as needed.

Oversee the intake, processing, and secure storage of any protected case review data

referred for evaluation.

Ensure timely and confidential handling of cases referred for peer review committee

evaluation.

Facilitate case progression through different levels of review, ensuring all necessary

documentation and follow-ups are completed.

Work closely with legal and compliance teams to adhere to peer review privilege

protections.

Coordinate peer review committee meetings, prepare agendas, and ensure appropriate

case materials are available.

Maintain accurate records of committee decisions, action items, and follow-up

requirements.

Track case resolution and communicate findings and recommendations to appropriate

stakeholders.

Ensure adherence to hospital bylaws, medical staff policies, and regulatory standards.

Identify trends in provider performance and recommend quality improvement initiatives.

Serve as a liaison between medical staff, quality improvement departments, and hospital

administration to foster collaboration and transparency.

Maintain secure and accurate records of all OPPE, FPPE, and peer review activities.

Develop and present reports to medical staff leadership and quality committees on

provider performance trends.

Support audits and accreditation surveys as needed.

Phoenix Children's Mission, Vision, & Values

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by :

Values