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.

• 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.
• OPPE & FPPE Data Management
  
  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.
• Protected Case Review & Peer Review Process
  
  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.
• Peer Review Committee Support
  
  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.
• Quality & Compliance Oversight
  
  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.
• Data Integrity & Reporting
  
  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.
• Performs miscellaneous job related duties as requested.
  

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

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:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable