Reporting to the Director, CMS & State Regulatory Compliance and working closely with the Clinical Team, the LSC Specialist, has primary responsibility for assessing and monitoring LSC related client and survey issues including objections, waivers, and immediate jeopardy identification for both Medicare and Ambulatory programs. This position is responsible for ensuring timely review and management of escalated survey reports and Plans of Correction, in accordance with CMS, state and AAAHC requirements. Success in this role requires active knowledge and utilization of Life Safety Code and Health Care Facilities Code (NFPA 101 and 99), effective workflow and workload management, and working knowledge of regulatory reporting requirements with focus on timeliness, thoroughness, and accuracy.

Primary Duties & Responsibilities:

• Serve as the AAAHC physical environment subject matter expert (SME) for daily Account Representative, Surveyor and client support, Surveyor and client education program content development, Standards and related policy revisions, and public comment/requests for opinion input.
• Evaluate and analyze complex LSC survey reports, client Plans of Correction, Standards Interpretation objections, and other related inquiries related to life safety codes, environment of care, and patient safety initiatives to determine the appropriate deficiency level, sufficiency of corrective action plans, and / or issue resolution. Provide technical support and guidance to AS Account Management team, Surveyors and client organizations.
• Collaborate with SVP, Accreditation Services and Clinical Director to provide Standards interpretation and monitor compliance with survey requirements.
• Provide expert review on client change notifications to determine need for additional information, onsite survey or escalation to Accreditation Committee (AC) Work Group for review.
• Participate in virtual and in-person conferences and state/federal meetings representing AAAHC.
• Collaborate with Director, CMS & States Regulatory Compliance to ensure ongoing compliance with CMS and contracted-state regulatory requirements.
• Maintain up to date knowledge of Life Safety and Building Codes, CMS and contracted-state regulatory standards, and communicate technical changes across AAAHC operational areas, Standards Development, the IQI and Learning departments as appropriate.
• Provide Life Safety and Environment of Care consultation and guidance to client organizations across all AAAHC programs, including analysis of validation surveys and CMS survey notification reports; serve as AAAHC LSC liaison for CMS.
• Participate in the development and presentation of educational programs for internal and external audiences. Serves as faculty for Surveyor and client education on Standards and NFPA codes.
• Develop, review and update Environment of Care Standards and LSC Guidance, Surveyor resources, and survey guidelines.
• Identify trends to inform educational tool development, Standards revisions, and individual Surveyor or Account Representative performance assessment.
• Assist Account Representatives in review of escalated objections to LSC findings in Plans of Correction; includes researching code requirements and conducting phone calls with clients to explain code requirements as needed.
• Review waiver requests and provide feedback to clients on changes needed to better support the request.
• Develop and maintain a database of Standards interpretation guidance and respond to staff, client and Surveyor requests for Standards interpretation received through email, phone call, “Ask the Expert” portal, or community chat rooms.
• Maintain proficiency and credentialing (badges) as an AAAHC Surveyor sufficient to perform AAAHC QC Random and Discretionary and Immediate Jeopardy Surveys triggered by complaint investigations.
• Serve as Staff Liaison for the AAAHC Medicare Expert Content Committee (ECC-MDS): schedule meetings/conference calls, prepare meeting agendas and related materials, draft meeting minutes, draft and revise official memos as a result of decisions made, properly document, log and file all decisions, action and findings communication.
• Contribute to the development and measurement of quality assurance and performance management indicators for the ongoing creation and refinement of existing AAAHC MDS program Standards including Life Safety Code guidance requirements; collaborate with the Learning departments to ensure inter-rater reliability regarding standard interpretations, and client and Surveyor understanding of standards requirements.
• Represent AAAHC as faculty at industry meetings and conferences, as requested. Participate in tradeshows as an AAAHC representative and serve as faculty for the AAAHC Achieving Accreditation program and other education initiatives.
• Responsibilities include all accreditation and certification programs.

Qualifications:

• Minimum of eight years ambulatory or hospital experience in engineering or safety management (e.g., mechanical, electrical, civil, biomedical, safety officer, or occupational safety and health specialist)
• Knowledge of Environment of Care Standards including Life Safety Code (NFPA 101) and Health Care Facilities Code (NFPA 99)
• Specialized knowledge of building systems, utility systems, and fire protection systems (i.e., smoke detection and sprinklers)
• Current certification / licensure / registration in a field related to plant, technology, and safety management [i.e., Certified Healthcare Facility Manager (CHFM), Certified Healthcare Safety Professional (CHSP), Healthcare Environmental Manager (HEM), Certified Industrial Hygienist (CIH), Certified Safety Professional (CSP), Professional Engineer (PE)] or able and committed to attain within one year of hire
• Customer service oriented
• Well organized, analytic problem solver, and detail oriented
• Independent thinker and problem solver; requires minimal supervision
• Demonstrated time management, multi-tasking, and project management skills
• Excellent verbal and written communication to a wide variety of audiences including regulators and other health care professionals
• Microsoft Office Proficient (i.e., Word, Excel, PowerPoint)

Excellent Benefits Including:

• 37.5 hour workweek
• Generous paid time off that increases with tenure - starts at 4 weeks off!
• 11 paid company holidays
• Hybrid work schedule - in office Monday-Wednesday
• 401(k) with company match in addition to employer contribution
• Generously-subsidized medical insurance with 4 plan options
• Generously-subsidized dental insurance
• Company-paid life insurance with additional voluntary life options
• Vision insurance
• Dependent care FSA
• Gym membership reimbursement
• Complimentary snacks in the office
• Public Service Loan Forgiveness (PSLF) eligible employer
• Employee assistance program
• Career growth opportunities
• Dress for your day policy
• Employee referral bonuses
• Continuous education opportunities