Physician Peer Review Coordinator

Memorial Hermann

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

Position is responsible for coordinating and facilitating the physician peer review system in compliance with The Joint Commission and other regulatory standards in conjunction with the Manager of the Physician Peer Review System. Must be able to demonstrate knowledge and skills necessary to perform all job related activities as outlined below.

Job Description

Minimum Qualifications

Education: One (1) of the following required:

  • Associates Degree in Nursing (ASN) from an accredited school of professional nursing required; Bachelor of Science in Nursing (BSN) preferred or
  • Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school required.


  • Current State of Texas license/permit to practice professional nursing or
  • Licensed to practice as MD or DO in the state of Texas.

Experience / Knowledge / Skills:

  • Minimum six (6) years of acute care, hospital-based clinical experience in area of intended practice.
  • Demonstrated knowledge of acceptable professional standards and practices.
  • Ability to work collaboratively with physicians and other healthcare professionals at all levels to facilitate the physician peer review process.
  • Ability to review, summarize and analyze medical records.
  • Demonstrated proficiency in word processing, EMR, Microsoft word and basic PC skills.

Principal Accountabilities

  • Works in conjunction with the Manager of the Physician Peer Review System to coordinate the Physician Peer Review Process which entails the analysis of medical records.
  • Reviews, analyzes and summarizes medical records for use in the Physician Peer Review Process
  • Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) reports.
  • Attends Physician Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee.
  • Oversees physician peer review data is entered into the Integrated Credentialing Management Program in a timely and accurate manner.
  • Maintains knowledge of Joint Commission and other regulatory agencies’ standards/regulations pertaining to the physician peer review process.
  • 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 Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
  • Other duties as assigned.

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