Laboratory Quality and Compliance Manager

We are recruiting for a mission-driven Laboratory Quality and Compliance Manager to join our team!

We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey.

Our Values

Respect | Belonging | Accountability | Transparency

Department

Laboratory Services

Work for an ASCP-designated Leading Laboratory, recognized for excellence in quality outcomes, professional development, trusted leadership, and laboratory visibility.

Job Summary
Under minimal supervision, reports to the Laboratory Administrative Director and the Laboratory Director of Services. Incumbent is responsible for the establishing, maintaining, and monitoring a centralized quality improvement program for the Denver Health laboratory, ACS laboratories, School Based clinic laboratories, Public Health laboratories, Point of Care testing, and any and all other clinical laboratories affiliated with Denver Health. Ensures continuing conformance with all legal and accrediting agencies' required for the laboratory. Incumbent is the liaison to other services across the Denver Health enterprise as a consultant, mentor, and teacher coordinating laboratory standards and compliance.
Essential Functions:

• Establishes an effective presence in the laboratory and patient care units to promote open communication between employee, supervisors, and those the laboratory serves. (15%)
• Plans, organizes and administers a performance improvement program for the laboratories that meets criteria for on-going actions for improved patient and testing outcomes. (5%)
• Develops and implements an annual performance improvement plan for the laboratory. (5%)
• Submits laboratory quality reports to the hospital quality program in a timely manner and as needed to provide support to quality activities, to represent patient advocacy through laboratory quality and encourage changes for better outcomes. (5%)
• Organizes and administers the Laboratory QI Committee which serves as an educational tool to laboratory staff through the review of specific patient events or current laboratory processes/workflows. (5%)
• Track changes, accomplishments and activities of the committee. (5%)
• Monitors individual department projects, laboratory projects, and mentors for use of tools, quality outcomes and individual and departmental growth. (5%)
• Participates in interdepartmental committees and lean activities to promote performance improvements, process changes. (5%)
• Initiates formal/informal activities with employees regarding departmental cohesion and collegiality for quality processes and outcomes. (5%)
• Assigns and completes investigations as needed with safety incidences and when required, participates with other departments in the organization in process change activities. (Example: Quality Process Improvement (QPI), Medical Quality Improvement Conference (MQIC). (5%)
• Conducts special studies at the request of management to provide facts, numeric outcomes to study complex issues for improvements, audits, and/or surveys (5%)
• Researches compliance regulations to ensure laboratory compliance, predict changes required by developing standards. (5%)
• Distributes compliance requirements to all supervisory staffs and confers with them to determine the extent of compliance. (5%)
• Educates, mentors and prepares all departments performing testing for regulatory compliance and standard interpretation. (5%)
• Acts as a liaison and consultant resource for intra and interdepartmental compliance questions and/or issues. (5%)
• Works with the regulatory compliance staff and assists in developing a compliance plan for the laboratories. Educates employees on compliance regulations and assures conformance with these regulations. (5%)
• Monitors the laboratories proficiency testing programs to ensure timeliness of reporting, action plans for improvement when there are failures, and appropriate testing challenges across all entities performing patient testing. (5%)
• Completes the Joint Commission “Focused Standard Assessments” when assigned in conjunction with the department staff and provides documented action plans for regulatory compliance. (5%)
• Participates in tracers, mock surveys, and survey activities in order to maintain compliance with accrediting agencies. (0%)

Education:

• Bachelor's Degree Required

Work Experience:

• 4-6 years Four years of laboratory experience, required. Required

Licenses:

• MLSASCP-Medical Laboratory Scientist - ASCP - American Society for Clinical Pathology Required

Knowledge, Skills and Abilities:

• Knowledge of accreditation standards for the Joint Commission, American Association of Blood Banks, FDA, CMS, CLIA, and other regulatory agencies.
• Knowledge of inspections or surveys and the ability to implement corrective actions.
• Knowledge of environment of safety issues.
• Ability to write, review, and update policies and procedures and improvement plans.
• Excellent communication and customer relation skills to ensure patient safety and quality processes in the laboratory.
• Ability to perpetuate teamwork.
• Ability to display visuals and speak to all quality improvements to both inside and outside of the laboratory.
• Ability to coordinate, plan, or participate in quality assessments for improvements.

Shift

Days (United States of America)

Work Type

Regular

Salary

$86,300.00 - $133,800.00 / yr

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.

As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.