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Role Description

Under general supervision of the Field Director, reviews assigned functions in Pathology and Clinical Laboratory Program throughout the United States. Provides general evaluation services, education, and consultation consistent with applicable Joint Commission standards, policies, and protocols. Determines the degree of compliance with applicable standards.

• Conducts a thorough and credible evaluation of assigned services that meet laboratory accreditation criteria.
• Plans, reviews, and apportions review time so that all review requirements are addressed thoroughly.
• Reviews and evaluates pre-survey information; research, collects, organizes, and interprets information from multiple sources.
• Interviews physicians and staff to determine level of compliance with standards.
• Analyzes documents, such as performance data, and use of clinical practice guidelines, to assess the level of compliance with Joint Commission standards, evidence of performance improvement, and quality of care.
• Analyzes written self-descriptive program information.
• Participates in and/or conducts all required conferences and interviews; analyzes all data submitted by the organization.
• Documents all recommendations, providing adequate indication of non-compliance.
• Submits review findings in a complete and accurate manner to the Clinical Laboratory Scientist Surveyor.
• Interprets and explains the intent of the standards to the organization’s personnel.
• Consults with the organization during review concerning non-compliance, opportunities for improvement, and remedial action required.
• Recommends publications and other resources that clarify standards and/or demonstrates compliance with standards.

Qualifications

• Doctor of Medicine or Doctor of Osteopathy.
• Pathologist, Board Certified in Clinical and Anatomic Pathology.
• Certification requirement: You must hold a CPHQ certification (Certified Professional in Healthcare Quality) through National Association for Healthcare Quality (NAHQ) at time of hire or attain by 12/31/28.
• Five years of recent clinical experience, including at least two years in management, preferably laboratory, and two years demonstrated responsibility for oversight, decision-making, management, and improvement in histopathology and cytology.
• Demonstrated knowledge of pathology industry including trends, performance measurement, and improvement.
• Demonstrated knowledge of compliance requirements related to CLIA’88.
• Demonstrate general knowledge in areas of Anatomic and Clinical Pathology.

Requirements

• Ability to research, collect, organize, interpret, and communicate information for multiple sources (i.e., documentation, observation, interviews) to assess the degree of compliance with Joint Commission standards.
• Ability to critically review and analyze performance measurement data.
• Ability to objectively assess organization performance.
• Ability to differentiate and assess the adequacy of alternative/innovative approaches to standards compliance, consistent with survey policy and protocols.
• Ability to analyze and synthesize survey findings to provide conclusions, recommendations, and educational opportunities.

Benefits

• The Joint Commission offers a comprehensive benefits package. For an overview of our benefits package, please visit our Joint Commission Career Page.