Lab Quality & Compliance Program Manager

The lab quality/compliance program manager is responsible for monitoring and evaluating all quality assurance and maintaining all quality standards wherever laboratory services are provided. The manager tracks and trends all lab continuous quality improvement forms to maintain a record of all quality assurance monitors. This position is responsible for maintaining quality control through a database of all reported problems and unsuccessful proficiency testing to detect any trends, shifts or persistent exceptions. The manager is responsible for ensuring compliance and reporting with regulatory and accrediting agencies (i.e., CAP, AABB, TJC, NJDOH). This position is responsible for ensuring all educational and compliance standards are being met in the clinical services, laboratory and transfusion services.  The manager will oversee and advise staff educational and orientation activities and regulatory departmental activities.
 
The manager monitors laboratory quality, education and safety procedures, as needed, and ensures quality assurance standards are met in the clinical laboratory and pathology sections. The manager schedules and assesses laboratory staff and assists with the operational duties of the department, as required. This position assists in providing adequate staffing levels, as needed, in the laboratory staffing line rotation. The manager works with laboratory leadership and the Laboratory Medical Director to resolve quality control, patient or procedural problems and recommends enhancements to laboratory procedures.
 
The position will remain abreast of current developments in clinical laboratory, education and compliance in order to provide regulatory and compliance expertise. The manager is responsible for providing support and consultation to our clinical and IT partners.  The manager supports latest technology reviews according to regulatory guidelines.  The manager ensures quality assurance and regulatory standards are being met, as applicable.  This role is responsible for providing staff training and education as well as oversight of staff competency.  
 
This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to teamwork and cooperation.
 
 
QUALIFICATIONS

• EDUCATION:  Bachelor’s degree in medical technology, chemical, physical, health or biological sciences required. Master’s degree preferred. Laboratory certification course completion required within two years of hire (tracked by department leadership). This position also requires participation in 24 CEUs annually.
• LICENSE/CERTIFICATION: Green Belt Lean Six Sigma certification preferred. Otherwise, required with 2 years of hire.
• EXPERIENCE: Requires two years of healthcare experience and the ability to lead teams with previous leadership experience preferred. Good communication and attention to detail. Experience with onboarding and education. Experience with Microsoft Excel, Word, PowerPoint and Access required.  Proficiency in Clinical Applications preferred at time of hire. Experience with hospital and ambulatory oversight preferred. Incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

  
PERFORMANCE EXPECTATIONS
Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.
 
Strict compliance with laboratory fraud and abuse policies and requirements is an employment condition.
 
WORK ENVIRONMENT
Potential for exposure to the hazards and risks of the hospital environment, including exposure to infectious disease, blood-borne pathogens, hazardous substances and potential injury. 
 
Must have the ability to distinguish colors. 
 
The essential functions for this position are listed on the Assessment and Evaluation Tool.
 
Core competencies will be assessed primarily to the following patient population(s) served (with the exception of newborns):  All diagnoses/conditions of patients admitted to the hospital.
 
REPORTING RELATIONSHIP
This position reports to laboratory leadership and supervises incumbents, as applicable, for laboratory/transfusion services.
 
The above statement reflects the general details considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.