Quality and Privileging Manager (REMOTE)

Cooper Norcross Health, formerly Cooper University Health Care, is a leading academic health system affiliated with Cooper Norcross Medical School of Rowan University. Headquartered in Camden, New Jersey, Cooper Norcross Health has revenues of more than $3 billion and an A+ credit rating from both S&P and Fitch Ratings.

Cooper Norcross Health has nearly 14,000 team members, including more than 2,200 nurses, more than 1,200 employed physicians representing 95 specialties and subspecialties, and more than 700 advanced practice providers.

The health system operates MD Anderson Cancer Center at Cooper as well as four hospitals – its 663-bed flagship Cooper Norcross University Hospital in Camden, its 229-bed Cooper Norcross University Hospital Cape Regional in Cape May Court House,  Children’s Hospital at Cooper Norcross Health in Camden, and The Recovery Village Cherry Hill at Cooper, a substance abuse rehabilitation and inpatient treatment facility, in partnership with American Recovery Services.

Cooper Norcross University Hospital in Camden is the only Level 1 Trauma Center in South Jersey and the busiest in the region. The hospital has been recognized as a top-performing regional hospital by U.S. News & World Report’s Best Hospitals annual survey for eight years.

More than 2.54 million patients visit Cooper Norcross Health facilities annually. Its ambulatory network encompasses three outpatient surgery centers, seven urgent care centers, a wound care center, and more than 130 physician, physical therapy, and radiology offices extending from the Delaware River to the New Jersey shore.

Cooper Norcross Health, a not-for-profit health system, was named one of America’s Best Large Employers for 2026 by Forbes, ranking among the top 200 in the nation. Visit CooperHealth.org to learn more.

Responsible for facilitating the medical staff Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) functions in accordance with The Joint Commission Standards, CMS Conditions of Participation, National Committee on Quality Assurance, and other regulatory requirements.  

Ensure that clinical reviews are timely, effective and appropriately documented.   

Responsible for the delineation of clinical privilege management.  

Collaborate with the Department Chief and/or Division Head to solicit updates/modifications to existing delineations to ensure privilege forms remain current, reflect clinical practice, and are consistent with industry standards.

For new privileges, the Quality and Privileging Analyst will compile information relevant to the privileges requested which may include appropriate privilege criteria, position and opinion papers from specialty organizations, white papers from the Credentialing Resource Center and documentation from other health systems, as appropriate.    

Responsible for facilitating the provider change in privileges credentialing process. Collaborate with providers and clinical departments to complete modifications in provider privileges regarding the addition of new privileges, department transfers and/or change in Medical Staff category/status.

Oversees the Focused Professional Practice Evaluation (FPPE) process in coordination with Medical Staff Department Chiefs, Division Heads, and other clinical leaders.

Facilitates the collection of key data elements to ensure compliance with FPPE requirements. Tracks the timeliness of FPPE evaluations and ensures accurate documentation within provider files and the Medical Staff credentialing system. 

In collaboration with clinical leadership, develops and oversees Ongoing Professional Practice Evaluation (OPPE) indicators to align provider performance data with Joint Commission accreditation standards and organizational goals.

Analyzes assessment and documentation data to ensure regulatory compliance and identifies performance trends that may pose risks to patient safety or the organization.

Oversees and supports the completion of OPPE evaluations, reports, and scorecards in collaboration with Department Chiefs and Division Heads. Partners with Quality Management leadership and staff to collect, review, analyze, and report data related to quality improvement and professional practice. Identifies performance trends that may impact patient care outcomes or the organization’s financial performance.

Monitors the timeliness of OPPE evaluations and ensures comprehensive and accurate documentation in provider files and the Medical Staff credentialing system.

Management of the quality reporting platform (e.g. Premier or Vizient) with regards to preparation of OPPE Profiles.  Ensures OPPE profiles are kept up-to-date and accurate, adding and removing providers as necessary. Prepares OPPE profiles for Medical Staff Office reappointment process.

Develops methods to efficiently manage FPPE sand OPPE process including workflows, procedures, and compliance expectations consistent with CMS and TJC standards.  

Prepares and submits reports of FPPE and OPPE to Credentials Committee. Participates in regulatory surveys and audits as the expert regarding the organizations’ FPPE and OPPE processes. 

Regularly solicits updates/modifications to specialty specific delineation of privilege forms to ensure forms remain current, reflect clinical practice and are consistent with industry standards, including maintenance of privileges within the credentialing software.

Researches privilege criteria for technologies or procedures new to the organization. Provides support to Medical Staff Office credentialing staff when interpreting clinical nomenclature (i.e., matching case logs to privileging criteria).    

Facilitates the credentialing process for providers requiring modifications to privileges due to the addition of new privileges, relinquishment of privileges, department transfers and/or changes in

Medical Staff category/status. Coordinates with providers, clinical department leadership and

Credentials Committee reviewers. 

Assists with other Medical Staff Office departmental activities as identified and assigned.  

Five (5) years of clinical nursing experience. Five (5) years of progressively responsible professional experience managing databases in a healthcare setting.

Analytical and quantitative skills related to collecting, organizing and summarizing various levels of data essential.

Expertise querying clinical databases, using clinical decision software and performing biostatistical analysis. 

Expertise with Microsoft Office a must. Experience in performance improvement programs required.

Bachelor of Science in Nursing (BSN) Required and/or Master of Science in Nursing (MSN) Preferred.

Current RN Licensure required. New Jersey RN licensure required, with the following exception: for 100% remote RNs, they must hold current RN licensure in the state of their primary residence.