Medical Staff Privileging and OPPE Coordinator

Department Overview

The OHSU Health Medical Affairs Department supports physicians, advanced practice providers, and clinical leaders through credentialing, privileging, medical staff governance, practitioner performance evaluation, and regulatory compliance. Partnering across the OHSU Health System, the team helps ensure qualified practitioners deliver safe, high-quality patient care while meeting accreditation and regulatory requirements in support of OHSU's mission of healing, teaching, and discovery.

The Medical Staff Privileging and OPPE Coordinator serves as a subject matter expert within Medical Affairs, responsible for the development, implementation, and continuous improvement of medical staff privileging processes. This role ensures that privilege delineation criteria, OPPE (Ongoing Professional Practice Evaluation), and FPPE (Focused Professional Practice Evaluation) processes are compliant with regulatory, accreditation, and organizational standards.

Under the direction of the Director of Medical Affairs, the Coordinator leads the development of privileging activities, supports FPPE/OPPE processes, and serves as a key resource for these duties to Medical Staff leaders and stakeholders. This position also provides back-up support for credentialing system reporting (Credential Stream) to ensure continuity of data access and reporting capabilities.

Function/Duties of Position

Privileging program leadership and coordination

• Serve as the subject matter expert for medical staff privileging for OHSU and HMC.
• Lead the coordination, development, standardization, and continuous improvement of privileging processes, ensuring alignment with regulatory (CMS, DNV) and organizational requirements.
• Collaborate with Medical Staff leadership, clinical departments, and administrative stakeholders to ensure consistent application of privileging standards.
• Facilitate communication, problem-solving, and project coordination related to privileging initiatives.
• Prepare and present reports, analyses, and recommendations to Medical Staff committees and leadership. 

Privileging criteria development and maintenance.

• Lead the design, development, and revision of privilege delineation forms and associated criteria.
• Conduct research and benchmarking to ensure evidence-based, current, and defensible privileging criteria.
• Coordinate interdisciplinary review and approval processes for new and revised privilege forms.
• Perform ongoing audits and routine reviews to ensure accuracy, consistency, and compliance of all privilege documents.
• Maintain privileging content within the credentialing database to ensure real-time accuracy and accessibility

OPPE and FPPE Program Coordination

• Coordinate and oversee the implementation and ongoing management of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) processes.
• Partner with Medical Staff leaders to develop meaningful, specialty- specific OPPE/FPPE metrics tied to privilege criteria and clinical performance.
• Ensure timely data collection, analysis, reporting, and follow-up actions for OPPE/FPPE activities.
• Monitor compliance with accreditation standards and support continuous improvement of practitioner performance evaluation systems.

Credentialing systems and data management 

• Maintain and optimize privileging and evaluation data within the credentialing system (Credential Stream).
• Serve as backup support to the Computer User System Analyst (CUSA) for the credentialing database, including:
  • Running standard and ad hoc reports
  • Supporting data extraction, validation, and analysis
  • Assisting with system workflows related to privileging, OPPE, and FPPE
• Ensure data integrity, accuracy, and compliance with privacy and security standards.

Education, training and consultation

• Act as a recourse for medical staff, leadership, and Medical Affairs personnel regarding privileging criteria, OPPE/FPPE processes and regulatory expectations.
• Provide training and education on privilege forms, evaluation methodologies and system workflows.
• Support ongoing competency development of staff related to privileging and evaluation processes.

Required Qualifications

• Three years of experience administering or coordinating parts or subsets of a project or program.
• A bachelor’s degree in business administration, Management, Public Administration, or a field directly related to the position will substitute for two years of the required experience.

Preferred Qualifications

• Experience with CredentialStream.
• Medical coding knowledge
• CPCS or CPMSM

Additional Details

Work is performed in a remote office environment. Requires prolonged periods of sitting and computer-based work, with frequent interaction via email, virtual platforms, and phone. May require attendance at meetings outside of standard business hours. Work schedule is Monday through Friday in the Pacific Standard time zone. A flex schedule may be available after successful completion of six-month probationary period.

Why apply to OHSU?

We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact [email protected]