Job Description

Provides interpretation and application of Joint Commission LAB Accreditation standards with special emphasis on CLIA requirements. Combines systems analysis skills with in-depth general and program-specific knowledge to evaluate health care organizations’ compliance and ability to provide high quality, safe patient care. Participate in the development and revision of standards and survey process. Participate in ongoing accreditation services and special projects. Serves as faculty for internal and external education programs. Represents Joint Commission to professional organizations. In conjunction with the operations team, ensures that accredited organizations receive excellent customer service and that their accreditation needs are met.

Responsibilities

• Provides expert guidance and interpretation of Joint Commission standards, CLIA requirements, professional standards of practice, and applicable laws and regulations to internal and external stakeholders.
• Conducts high-level analysis of organizational data, including performance measures, survey outcomes, and corrective action submissions, to identify actual or potential risks impacting quality and patient safety.
• Coaches and mentors customers on corrective action development, emerging healthcare issues and trends, and leading practices, including effective use of Joint Commission tools and resources.
• Supports the accreditation and certification process through development, review, and analysis of survey reports and outcomes, collaboration with field representatives and accredited organizations, and recommendations regarding accreditation/certification decisions.
• Supports the complaint analysis process through complaint review, identification of potential standards noncompliance, development of assessment maps, and participation in preparatory conference calls, as needed.
• Provides leadership and guidance to service teams across all aspects of the accreditation process, leveraging clinical expertise and customer relationship management skills.
• Serves as a role model in advancing enterprise, division, and departmental initiatives, utilizing Robust Process Improvement (RPI) tools and strategies; leads and participates in internal workgroups to improve processes and outcomes.
• Ensures consistent standards interpretation through inquiry management, FAQs, education, publications, and media/social networking activities.
• Serves as faculty for Joint Commission field representative training, Speaker’s Bureau engagements, and seminars and workshops; participates in program-specific committees as assigned.
• Communicates effectively and professionally with internal and external customers, consistently demonstrating a respectful, constructive, and collegial approach and a commitment to excellent customer service.
• Embraces and models the Joint Commission culture of safety, incorporating Department Guidelines into daily work and interactions.
• Serves as a resource in developing responses to external media inquiries and supporting interview requests, as appropriate.

Qualifications

• Medical Laboratory Scientist or Medical Technologist with master’s degree and a minimum of five years of experience.
• Joint Commission Lab experience strongly preferred.

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