This individual is responsible for coordinating and supporting continuous regulatory and accreditation compliance oversite and survey readiness activities for Pathology and Laboratory Services throughout the NHRMC network. Accreditation agencies include: The College of American Pathologist (CAP), American Association of Blood Banks (AABB), Clinical Laboratory Improvement Amendments (CLIA), FDA, DNV and various organizational accreditation-related entities. This role includes the development, implementation and ongoing maintenance of training, education, and competency assessment programs associated with accreditation. This role preforms a wide variety of technical, reporting and support responsibilities that provide accurate, timely, quality statistical analyses, analytical reviews. Generates reports to Pathology and Laboratory leadership for accreditation-related organizational activities/projects. Provides data for drill down capability for follow-up and performance improvement. Requires expert knowledge of Microsoft Office Suite, electronic databases, and applications This individual has no patient contact.
1. Coordinates and supports continuous regulatory and accreditation compliance oversite and survey readiness activities for Pathology and Laboratory Services. Supports organization-wide survey readiness. 2. Role includes development, implementation and ongoing maintenance of training, education, and competency assessment programs associated with regulatory and accreditation agencies. 3. Ensures laboratory compliance with all regulatory rules and organizational standards, as they relate to individual job tasks. 4. Serves as a NetLearning and CAP Competency Administrator. 5. Responsible for submission of regulatory and accreditation compliance documentation i.e. AABB, CAP, CLIA applications and reapplications; self-inspections and deficiency responses; and evidence of compliance documentation. 6. Maintains all regulatory and accreditation documentation. Maintains accurate spreadsheets of AABB, CLIA and CAP certifications and accreditations. 7. Maintains safety and inspection records per standard requirements. 8. Serves as a superuser for PolicyStat policy management software. 9. Serves as a resource for billing compliance and reimbursement. 10. Serves as a resource for laboratory quality assurance. 11. Creates and implements various strategies to collect data to provide accurate and timely data, analysis, and reports for compliance and accreditation-related organizational activities/projects. 12. Responsible for producing a meaningful summarization and analysis of data for assessment and interpretation in a logical manner, providing report and information for drill down capability for follow-up and performance improvement. 13. Coordinates the distribution of timely and meaningful reports/quality improvement practices in order to facilitate effective problem solving and action plans. 14. Supports laboratory and systemwide performance improvement projects. 15. Responsible for maintaining and distributing dashboards/reports to leadership. 16. Initiates reports for accreditation audits tracers, laboratory safety rounds and provides direction and instruction to users when applicable. 17. Provides support and compliance oversite of for laboratory safety across network laboratories. 18. Provides support for accreditation action plan timelines and measurement data as follow-up to deficiencies and plans of correction. 19. Provides support for compliance and accreditation continuous readiness initiatives organization wide. 20. Primary support for communications and logistics for Pathology and Laboratory leadership during unannounced regulatory surveys, ensuring that resources and information needed is readily available and accessible. 21. Maintains a current regulatory and accreditation knowledge base related to the multiple specialty areas within Pathology and Laboratory services. 22. Participates in short-range planning, professional development of staff, budget process, goal setting, development and completion of action plans, works with manager and in development of strategic plans. 23. Acts as a resource for staff, patient caregivers, laboratory management, and the medical directors. 24. Provides and/or supports project and change management as needed. 25. Organizes and performs work effectively and efficiently, including communication that is clear in written and oral format. 26. Demonstrates positive interpersonal relations in dealing with all members of the team and external stakeholders. 27. Prepares all work with maximum independence, accuracy, and completeness, acting with insight and forethought. 28. Must be proficient with Microsoft Office Suite. 29. Ensures that the Service Excellence Initiative is standardized throughout all laboratories. 30. Orders supplies as needed.
- Medical Technologist
- Medical Laboratory Scientist
Education: Bachelor's degree in biological sciences, Medical/Clinical laboratory science or Medical Technology.
Licensure / Certifications: Medical Technologist or Medical/Clinical Laboratory Scientist (preferred).
Experience: 3 years in a laboratory environment. 3 – 5 years in a laboratory compliance role preferred.
Other (hours of work):Hours vary according to assignment.
Population Served:Neonate (0-28 days), Infant (1-12 months), Child (1-12 years), Adolescent (13-17 years), Adult (17-72) years and Geriatric (72+ years).
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. Performs other duties as assigned. Individual will possess commensurate combination of education, experience and qualifications.