GENERAL SUMMARY:
Responsible for managing all aspects of the Laboratory compliance program including conducting and overseeing internal compliance audits and investigations; developing and implementing content for laboratory compliance education and training; and collaborating with the Laboratory Compliance Committee to define, implement and maintain policies and procedures that support the Laboratory Compliance Plan and help ensure ethical business practices and compliance with Federal, State and local laws and accrediting requirements. This position reports to the Outreach Operations Director.
AREAS OF RESPONSIBILITY: Dearborn, Grosse Pointe, Royal Oak, Taylor, Trenton, Wayne and Lab Outreach
ESSENTIAL DUTIES:
- Conducts or oversees internal laboratory investigations including communications, self-assessments, monitoring and auditing to identify compliance vulnerabilities and risks and improve effectiveness of the Laboratory Compliance Plan. Analyzes data and presents findings including recommended corrective and preventative action plans to the Laboratory Compliance Committee. Prepares department compliance reports as required by Compliance. Monitors status of remedial actions including conducting or overseeing follow-up monitors or audits.
- Develops, implements, and maintains the Laboratory Compliance Plan and associated policies and procedures in collaboration with the Laboratory Compliance Committee. Monitors regulatory and accrediting publications to proactively identify potential compliance risks for more detailed evaluation. Collaborates with Operations and others as appropriate to develop and maintain lab encounter forms.
- Establishes compliance education content and develops learning tools and communications that support staff and client compliance education activities. Monitors mandatory education to ensure compliant participation.
- Investigates complaints or conduct access certification reviews as requested byCompliance Audit, Risk and IT Security Department. Reviews contracts, agreements and other documents for compliances risks seeking legal advice where appropriate. Maintains laboratory services agreements and works directly with Beaumont Health Office of the General Counsel to update content based on operational need and laboratory service models. Initiates the appropriate Laboratory agreement with external parties utilizing approved BH contract database and maintains oversight to completion.
- Manages day-to-day operation of the Laboratory Compliance program including overseeing compliance activities assigned to Data Technician or other support staff.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.
STANDARD QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
- Education / Training:
Bachelor degree required, master preferred.
- Work Experience:
5 years lab experience with 3-5 years supervisory / management experience (Laboratory preferred). Additional experience desired includes knowledge of compliance principles and regulatory requirements; major LIS software (clinical and financial), and laboratory coding and billing.
- Certification, Licensure, Registration:
MT (ASCP) or CLS /Laboratory Certification preffered.
- Other Qualifications:
Excellent communication skills (verbal and written), computer software proficiency (Word, Excel, Access, Power Point, etc). Excellent analytical skills and ability to handle several responsibilities simultaneously. Experience doing on-line research. Specialized in the area of keeping on top of regulatory matters and changes and being able to handle multiple issues at one time.
