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At Cedars-Sinai, we're motivated by a collective spirit of innovation and the challenge to continuously improve. Above all, we share a real passion for helping others. Day after day, from department to department, our people give their all to create a community unlike any other. This is just one of the many reasons U.S. News & World Report has named us one of America’s Best Hospitals—and now we invite you to join us and make a difference every single day in service of this outstanding work – excellence and innovation in patient care, research, and community service. From working with a team of dedicated professionals to using state-of-the-art facilities, you’ll have great resources to do something incredible—for yourself, and for others

What you will be doing in this role?

The Associate Director, Medical Affairs is responsible for the administrative oversight and day to day operations of the Well-Being of Physicians Committee, the Medical Staff’s Peer Review Process and the Medical Staff’s Ongoing Professional Practice Evaluation (OPPE). This work must be in accordance with the Medical Staff Constitution, Medical Staff General Rules and Regulations, accreditation, regulatory, and licensing requirements.  In addition to the ongoing and day to day management of the above processes, this position is also responsible for trending key performance indicators (KPIs) pertinent to the Well-Being, Peer Review and OPPE, sharing with senior leadership, implementing best practice in these areas, and continually evolving these processes to ensure optimal effectiveness and efficiency.  This position reports directly to the Executive Director of the Office of the CMO and works closely with the Associate Chief Medical Officer/Vice-President of Medical Affairs, other senior executives in the Office of the CMO, Medical Staff leadership and leadership across the organization.    

Primary Duties and Responsibilities

• Provides leadership, guidance, and direction for day-to-day program operations, administrative activities, and staff relevant to Well-Being of Physicians Committee, Medical Staff Peer Review, and Medical Staff OPPE. 
• Interfaces with internal and external key stakeholders including other departments, leaders across the organization, and representatives from external agencies/organizations in the management of the program to provide guidance, resolve issues, grow the program, and/or implement processes and/or solutions.  Identifies and defines any logistics, action items, changes, or information needed to effectively manage the program. 
• Identifies opportunities for process improvements and introduction of best practices within the department function.  Participates in organizational process and/or efficiency initiatives as applicable and related to areas of expertise.
• Drives change by providing centralized development, implementation, and oversight of programs and initiatives designed to improve and support relevant programs. 
• Assesses communication and training needs, develops and implements any applicable communication, education, training, on-boarding and/or mentorship pertaining to the program. Provides regular communication to departments and leaders across the organization. Notifies stakeholders of any changes to the program. May work with cross-functional teams across multiple departments to develop communication and training materials.
• Maintains data system integrity and ensures quality assurance measures are followed based on departmental standard operating procedures. May provide ad hoc reporting to support recommendations observed through trend analysis for future planning and enhancements.
• Monitors program to ensure appropriate governance and program compliance with local, state, and federal laws; accreditation, professional and regulatory agency standards, and licensure requirements.  Maintains staff and program compliance with organizational policies and procedures.
• Demonstrates initiative, resourcefulness, and problem-solving skills in applying a detailed knowledge of the responsibilities, functions, and underlying management structure of the department and of the larger health system in organizing and prioritizing work, establishing procedures and systems, and ensuring the orderly and timely flow of operations.
• Resolves and reconciles peer review problems and discrepancies. Serves as the primary resource to hospital and Medical Staff leadership regarding the Peer Review process. Provides consultation to medical staff, senior and service line leadership on complex cases and incorporates concepts of safety and standards of care into daily work.
• Facilitates peer review within respective departments and assists with the review of additional cases, when required for ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE).  Guides physician reviewers / medical staff leadership to pertinent information in the electronic medical record.  Assures that Case Review Worksheets are completed in a timely fashion.
• Creates and validates data for the monthly medical executive committee (MEC) and OPPE report to satisfy Medical Executive Committee and Joint Commission requirements. Oversees the OPPE schedule to assure chair sign off occurs approximately every six to eight months.
• Leads and facilitates elevated reviews to a Level II or III Proctoring including oversight of all written and verbal communication with department chairs, legal, senior leadership, and physician under review.
• Oversees the Physician Well-Being program process; ensures seamless application of activities such as handling of all communication, standing and subcommittee meeting coordination, reports, and minute maintenance. Provides guidance to committee chair in collaboration with Medical Affairs leadership and Medical Staff legal counsel.
• Ensures the protection and maintenance of confidential records of all meetings and maintenance of individual physician files; may support in preparing committee agenda in collaboration with respective committee chair. Serves as liaison and point of contact for correspondence with physicians referred to the committee.
• Ensures trending of key performance indicators pertinent to Well-Being, Peer Review, and OPPE

Job Qualifications:

Education:

• Bachelor's Degree in Nursing, Healthcare Administration, Management, Business Administration or related field required.  

Experience:

• At least five (5) years of experience working within a Healthcare quality management/performance improvement, program management, or related experience. 
• At least five (5) years of Managing Academic Clinical Department(s), Service Line(s), and/or related Department(s) in a Healthcare Setting