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Accreditation Coordinator - Laboratory

Charlotte, NC, United States
Job ID: 4131
Job Family: Professional Services
Status: Full Time
Shift: Day
Shift Details: Regular
Department Name: 21011017239003-Laboratory
Location: Charlotte - 2709 Water Ridge Pkwy

Overview

Job Summary
 
Oversees the daily continuous accreditation readiness for assigned facility(s). Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity.
 
 
Essential Functions
 

  • Leads continuous accreditation readiness efforts and coaches others in the development of accreditation improvement capabilities. Provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness.
  • Maintains expert competence in accreditation standards and communicates relevant changes to appropriate leaders and staff.
  • Maintains a close working relationship with facility leadership to optimize the quality and patient safety culture and to support constant state of readiness for accreditation reviews.
  • Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities. Compiles and distributes compliance reports including appropriate action plans to oversight councils. Supports and guides the facility in continuous survey readiness efforts.
  • Participates in the review, analysis and development of plans.
  • Prepares reports and presentations.
  • Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity. Re-assesses approach to maximize success.
  • Assists leadership in defining key performance indicators and developing measurement tools to evaluate quality improvements.
  • Utilizes facilitation skills (both team and individual), data analysis and statistical process control to effect improvement in quality and clinical outcome.
  • Consults with and trains staff to implement monitoring and measurement tools, and data analysis techniques. Provides education and training on accreditation compliance and accreditation matters.
  • Collaborates with staff to facilitate improvement teams to achieve facility and System quality and patient safety goals.
  • Assists with system and regional quality initiatives
  • Leads continuous CLAI/CMS regulatory compliance readiness for the AHMG physician office laboratories(POLs); acts as liaison between POLs and CLIA; is present for CLIA surveys and assists with Plans of Correction following surveys, if needed.
  • Compiles and distributes compliance reports using appropriate action plans to AHMG lab testing personnel and administration, using Verge tools. (Does not report to QCC and does not participate in Leadership Conference) 
  • Provides training and education for lab testing personnel; responsible for evaluation of testing personnel competency and performance. (does not train staff on data analysis techniques) 

 
Physical Requirements
 
Works in an office environment. Requires walking, standing, long periods of sitting and computer use. Intact sense of sight and hearing required. Travels to facilities as needed. Must have current state driver's license.
 
 
Education, Experience and Certifications
 

  • Bachelor's Degree required; Master's Degree preferred. RN or other clinical licensure preferred. Certification in healthcare quality, patient safety or related accreditation entity preferred, required within 1 year of employment. 
  • A baccalaureate degree from a regionally accredited college/university in chemical, physical, biological sciences, or medical technology (clinical lab science) required by CLIA. Successful completion of CLSI accredited Medical Technology/MLT (Clinical Laboratory Science) Program required. 
  • At least 2 years of lab training/experience or both in a non-waived (moderate or highly complex) lab in the areas of specialty or subspecialty (hematology/chemistry/microbiology) the technical consultant is responsible as required by CLIA.
  • At least 2 years’ experience that demonstrated competency in physician office laboratory practices preferred. 
  • Should have basic knowledge of CLIA regulatory requirements. 
  • Professional certification preferred.
  • At least 2 years of supervisory laboratory experience in non-waived testing preferred. 
  • Knowledge of PDSA and LEAN concepts preferred.