In this role, the candidate supports Clinical Laboratory and Pathology in maintaining inspection readiness for all laboratory sites. Assists with assigning staff training and assessing compliance with assigned training. Maintains records and licensure required for regulatory inspections. Documents audit findings to assess compliance with standards for The Joint Commission, Department of Health, College of American Pathologists, Environmental Protection Agency, etc. Assists with approval, training, and modification of department and system wide policies. Assists with annual reapplications to accrediting agencies and orders for proficiency testing and educational activities.
Essential Functions
- Assists the Regulatory Compliance manager with performing all departmental regulatory audits for assessment of compliance with CAP, DOH, CMS, JC, and EPA regulations. Issues detailed reports with findings and suggests corrective actions for each non-compliant finding.
- Performs follow up audits to assess compliance with corrective actions stemming from regulatory inspections and quality improvement initiatives
- Facilitate and monitor staff compliance with required trainings including Regulatory training, Lab Manual training, Environmental Health & Safety training. Follows up with any individuals that are out of compliance.
- Keeps track of licenses for MD, PhD, Technical staff and Reference Labs and ensure they are within the expiration date. Ensure staffs and MD files, including licenses, are up to date and accurate.
- Data Compilation: Critical Values, dashboard data, quarterly internal QIC submission
- Reviews any reports of diagnosis of communicable diseases and reports them as required by city and/or state law.
- Special projects: Assists with projects and special assignments as requested.
Minimum Qualifications
Bachelors Degree with 2+ years experience in clinical hospital setting.
Certified in Healthcare Compliance (CHC) by the Compliance Certification Board or eligible to sit for certification within 6 months of hire date
Experience interpreting regulations and preparing for regulatory inspections in the field of healthcare. Healthcare specific compliance work experience required.
Must have excellent Microsoft Office suite computer skills (Outlook, Word, Excel, PowerPoint, etc.) and superb organization skills.
Preferred Qualifications
Masters degree in business and or healthcare related discipline. Legal background a plus. Experience with hospital regulatory compliance. Knowledge of the laboratory sciences.
Familiarity with lab/pathology specific regulatory issues a bonus
Qualified candidates must be able to effectively communicate with all levels of the organization.
