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Providence Accreditation Manager, Laboratory in Tarzana, California


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Providence is calling an Accreditation Manager (Full-Time/Day Shift) to the Laboratory at Providence Cedars-Sinai Tarzana Medical Center in Tarzana, CA.

We are seeking an Accreditation Manager to the Laboratory who will develop, direct, and coordinate laboratory policies and procedures for quality improvement, quality assurance, regulatory compliance, accreditation compliance and patient and employee safety. Provide leadership to achieve quality through continuous quality improvement and quality review. Collaborate in developing quality, regulatory, safety and point of care strategies within the Laboratory and /or service area. Identifies customer needs and develops, with the Management Team, quality programs to meet those needs. Function as an expert on regulatory and compliance matters. Coordinate laboratory staff training and competency program. Oversee the Point of Care activity of the laboratory.

In this position you will:

  • Coordinate an ongoing quality program, including quality improvement activities for each section of the Laboratory and evaluates for effectiveness. Works collaboratively with Laboratory Administration to initiate and develop indicators and measurable outcomes. Assists in the analysis of isses, identification of root causes, designing solutions and monitoring of improvements.

  • Identify customer needs (interdisciplinary, patient, physician), responds to issues affecting safety and develops process improvement activities to address the needs.

  • Participate in all laboratory quality management meetings. Prepares an annual written review of the effectiveness of the quality management program, determining new monitors, and offering training as needed.

  • Coordinate an ongoing safety program. Prepares an annual written review of the safety program determining and implementing improvement opportunities.

  • Develop and maintain departmental systems and policies relating to improving laboratory quality staff competency, and coordinates the necessary in-service training to meet regulatory compliance.

  • Coordinate the ongoing Point of Care testing program including regulatory, testing, and reporting activities. Researches and recommends testing opportunities.

  • Ensure all laboratory employees are oriented, and have annual competencies relevant to their scope of duties and training for new processes are documented.

  • Develop and recommend programs for maintaining and ensuring accreditation with the following agencies: CLIA, TJC, CAP, DHS, OSHA, FDA, AABB. Coordinates inspection preparation activities to ensure that the laboratory is inspection ready for FDA, AABB, CLIA, TJC, State of California and CAP.

  • Ensure documentation is submitted for all laboratory and facility licensure and accreditation. Coordinates inspections, ensures identified deficiencies are corrected and responds in writing to the inspecting agencies in a timely manner.

  • Provide updates on relevant changes and issues in laws and regulations pertinent to the laboratory environment. Assesses the effectiveness of existing policies and procedures with regard to risk.

  • Manage the response and follow up to all laboratory related incidents reports (UOR etc.), recommends the implementation of any necessary corrective actions.

  • Evaluate the laboratory compliance program, including tool kits and internal audits ensuring all components and corrective action are met.

  • Ensure proficiency surveys are ordered, reviewed and follow-up corrective action is documented and meets requirements for accreditation and CLIA compliance.

  • Author all laboratory administrative, quality, safety, and point of care policies and procedures. Is responsible for Laboratory document control.

  • Maintain excellent relations with management, patient, medical staff, and other departments as well as other hospitals that use services. Answers questions and resolves issues with physicians, nurses or clients as needed.

  • Identify and evaluate trends in health care and regulatory requirements and develops strategies to respond to these trends. Develops written goals and objectives on an annual basis in coordination with Pathologists and laboratory management.

  • Maintain departmental reports and records, and collects statistical data for administrative and regulatory purposes.

  • Able to perform the duties of a clinical laboratory scientist, including tests and procedures.

  • Attend meetings as required, and participates on committees as directed.

  • Enhance personal and departmental professional growth and development through participation in educational programs, current literature, in service meetings, and workshops.

  • Other duties as assigned.


Required qualifications for this position include:

  • Licensed as a California Clinical Laboratory Scientist

Preferred qualifications for this position include:

  • Master's Degree

  • Five (5) years sufficient experience in all areas of the laboratory.

About the hospital you will serve.

Providence Cedars-Sinai Tarzana Medical Center is a 245-bed not-for-profit medical center that serves the San Fernando Valley, offering high quality specialty services, including: heart and vascular care, orthopedics, oncology and senior services. Recognizing the special health care needs of women and children, our Women’s Pavilion & Resource Center provides women’s health and maternity care in once central location. The hospital specializes in pediatrics and has one of the largest neonatal intensive care units in the San Fernando Valley. Providence Tarzana has a reputation for clinical excellence and sophisticated technology with a personal touch. Providence Health & Services cares about the people and the lives that we touch each and every day. We are continually driven by the caring tradition of our heritage – the foundation of our Mission and core-values – to embrace respect, compassion, justice, excellence and stewardship. With a rich past reaching back more than 65 years in Southern California, and 150 years in total, Providence Health & Services today celebrates unprecedented growth, recognition for top quality health care, a vibrant employee culture where new ideas are encouraged and a drive to help the underprivileged - all with an eye toward the future.

For information on our comprehensive range of benefits, visit:

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Non-Clinical Director/Executive

Location: California-Tarzana

Req ID: 273984