The Lab Manager is responsible for directing and overseeing all operational, technical, staffing, quality, and regulatory functions of the Laboratory Services department. This role fulfills the duties of Technical Supervisor and General Supervisor for a moderate and highly complexity laboratory as defined under 42 CFR 493.1451 and 42 CFR 493.1463, and serves as the primary quality management leader ensuring compliance with CLIA, The Joint Commission, CAP, Medicare, and all applicable state and federal regulations. The Lab Manager partners with the Director of Laboratory to develop and implement short- and long-term goals, manage departmental budgets, drive continuous quality improvement, and foster a culture of exceptional patient care and service excellence.
MISSION, VALUES and SERVICE GOALS
- MISSION: We deliver outstanding care, inspire health, and connect with heart.
- VALUES: Trust. Respect. Integrity. Compassion.
- SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
A. Operational Leadership and Departmental Management
- Directs daily operational activities of the laboratory department to ensure provision of high-quality, timely laboratory services aligned with patient care needs.
- Develops and administers short- and long-term goals and objectives for laboratory services, including plans and metrics to achieve departmental objectives.
- Develops, gains approval of, and administers the annual operating budget; monitors departmental financial performance through review of expense reports, invoices, and reagent/supply utilization.
- Works with contractors and service providers to recommend capital and operating purchases; monitors equipment uptime and assures high levels of performance.
- Develops new programs, revises existing programs, and performs financial analysis to provide comprehensive laboratory services meeting patient and medical staff needs.
- Interprets, enforces, and supports hospital policies, procedures, and protocols; recommends new or revised policies to enhance workflow processes.
- Represents the department to a variety of internal and external stakeholders, serving as primary liaison for laboratory services.
- Performs other duties and completes special projects as assigned.
B. Staffing and Associate Development
- Provides direct supervision for all laboratory associates, serving as a daily resource on operational and technical issues.
- Recruits, interviews, hires, and evaluates staff; recommends corrective actions, progressive discipline, and when necessary, discharge of associates.
- Prepares and administers associate performance appraisals in a timely and consistent manner.
- Provides leadership, coaching, and skill development to assigned associates; ensures each associate is properly trained and competency-verified for assigned duties.
- Oversees preparation of work, holiday, and vacation schedules to ensure adequate staffing and appropriate workloads at all times.
- Ensures all associates follow applicable policies, procedures, and regulatory requirements.
C. Technical and Regulatory Supervision
- Fulfills all duties and responsibilities of Technical Supervisor for a highly complex laboratory as defined in 42 CFR 493.1451 and 42 CFR 493.1461.
- Fulfills all duties and responsibilities of General Supervisor for a highly complex laboratory as defined in 42 CFR 493.1463.
- Maintains active competency in laboratory processing, blood bank, hematology, and chemistry departments; works directly in at least one department at least twice per month to maintain technical proficiency.
- Demonstrates solid knowledge of medical laboratory procedures and testing systems; ensures all testing practices conform to applicable laboratory standards.
- Maintains working knowledge of laboratory information systems and applications.
D. Quality Management and Regulatory Compliance
- Serves as the primary quality management leader for the laboratory, preparing quality management reports and reporting to quality committees as needed.
- Ensures the department and hospital continuously meet all accrediting agency requirements, including CLIA (42 CFR Part 493), The Joint Commission, CAP, Medicare, and applicable state regulations.
- Assists with reviewing quality control documentation including reagent checks, validations, instrument comparisons, quality control trends, and Levey-Jennings charts.
- Maintains the document management system for tracking and maintaining department standard operating procedures (SOPs).
- Performs CAP self-inspections and continuing education programs; maintains all associated documentation.
- Oversees proficiency testing programs, including documentation and timely review of and response to unacceptable results.
- Participates in hospital inspections by The Joint Commission, State Board of Health, CLIA surveyors, Stroke Certification teams, Trauma Certification teams, and other applicable bodies.
- Provides IQCP documentation and oversight in accordance with CLIA requirements.
- Maintains individual quality measures such as phlebotomy recollection rates and blood culture contamination rates; monitors scorecard metrics and leads operational initiatives to achieve satisfactory results.
- Conducts periodic audits to ensure the quality and integrity of laboratory operations and data.
- Participates in continuous quality improvement by identifying areas of opportunity and initiating necessary corrective actions.
- Analyzes operational problems, uses sound judgment to identify potential issues requiring management involvement, and facilitates timely delivery of solutions.
- Meets and collaborates with external organizations related to quality and clinical excellence metrics; ensures requirements for specialty lab tests are defined and communicated to appropriate associates.
E. Inventory and Supply Chain Management
- Specifies quality and source of laboratory products and equipment; negotiates contracts for identified products and equipment.
- Reviews expense reports and invoices, monitors budget performance, and audits use of reagents and supplies to ensure fiscal accountability.
F. Staff Training and Competency Assurance
- Interfaces closely with all team members to ensure initial, 6-month, and annual training and competency verification are completed in accordance with 42 CFR 493.1451 and applicable regulatory standards.
- Recommends and provides remedial training for team members when performance deficiencies are identified.
- Creates life-like test scenarios for training and competency assessment purposes.
- Acts as a safety officer for the laboratory department; ensures compliance with bloodborne pathogen standards, chemical hygiene plans, and all applicable safety regulations.
G. Customer Service and Stakeholder Relations
- Responds promptly to customer concerns and complaints; ensures customers are treated in a friendly and highly effective manner while providing timely resolution of service issues.
- Acts as a resource to all hospital departments regarding laboratory services and quality management processes.
- Participates in hospital and organizational committees as requested.
H. Professional Development and Personal Competency
- Continually reviews professional literature; attends seminars, conferences, and workshops to remain current with changes and innovations in laboratory practice.
- Maintains professional affiliations and memberships in relevant organizations.
- Attends in-services and department meetings; participates in continuing education and approved conferences.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
Required Education
- Bachelor's degree in Medical Laboratory Science (MLS), Medical Technology, or one of the biological sciences required.
- Must qualify as Technical Supervisor, Technical Consultant, and General Supervisor as defined in 42 CFR 493.1449, CFR 493.1411, and 42 CFR 493.1461 at time of hire or within 3 years of hire.
- Must qualify as Technical Consultant as defined by CAP within 3 years of hire.
Preferred Education
- Master's degree in Business Administration, Healthcare Administration, or Public Administration strongly preferred.
Required Experience
- Minimum of six (6) years of clinical laboratory experience required.
- Minimum of three (3) years of supervisory or leadership experience in a clinical laboratory setting required.
- Prior experience in a CAP-accredited laboratory required.
Required Certification
- Medical Laboratory Scientist, MLS (ASCP) certification or equivalent (HEW/HHS) required, or must be obtained within 3.5 years of hire.
Certification Pathways for Non-MLS Degree Applicants
- Applicants holding an associate's degree in Medical Laboratory Technology or a chemical, physical, or biological science with completion of a CAHEA-accredited Medical Laboratory Technician program may be considered for hire; however, must acquire a Bachelor's degree in Medical Laboratory Science (MLS) within 3 years of hire.
- Non-MLS degree applicants must acquire the Medical Laboratory Technician, MLT (ASCP) certification within 7 months of hire.
Knowledge, Skills, and Abilities
- Demonstrates advanced knowledge of medical laboratory procedures, testing systems, and day-to-day operations across all laboratory specialties.
- Requires working knowledge of applicable state and federal regulations and applicable accrediting agencies (CLIA, The Joint Commission, CAP, Medicare).
- Demonstrates the ability to develop and maintain departmental budgets and the financial skills necessary to track and manage department expenses.
- Requires technical knowledge of laboratory information systems and applications; demonstrates working knowledge of database applications and data mining tools.
- Requires strong analytical and problem-solving skills; ability to analyze situations and respond in a timely and efficient manner.
- Demonstrates strong leadership and organizational skills necessary to manage day-to-day operations and complex, overlapping priorities under deadline pressure.
- Demonstrates excellent interpersonal and communication skills (verbal and written) necessary to communicate effectively with associates, medical staff, leadership, and external stakeholders.
- Demonstrates advanced ability to develop, deliver, and evaluate effective training and competency programs for laboratory staff.
- Demonstrates a strong commitment to leadership development and a desire to participate in management development activities.
- Complies with hospital expectations regarding ethical behavior and standards of conduct.
- Complies with all federal and hospital regulations regarding protected health information (PHI) and patient privacy (HIPAA).
Working Conditions
- Works primarily in a clean, well-lighted clinical laboratory environment with controlled temperature and ventilation.
- May be exposed to infectious disease from contaminated biological materials; may handle toxic or corrosive substances. Risks are minimal when proper safety procedures are consistently followed.
- Must have the ability to work varied hours as operational needs demand, including evenings, weekends, and on-call as required.
- Travel may be required for external CAP inspections, professional conferences, or system-level meetings.
- Must be able to function effectively in a fast-paced, quality-focused, multi-priority environment that frequently involves stressful situations and critical deadlines.
