Job Summary: The Compliance Specialist – Engineering manages the facility engineering Environment of Care and Life Safety programs associated with The Joint Commission and Centers for Medicare & Medicaid Services requirements. This person ensures all documentation is current and accurate while confirming all regulatory and required testing is completed within the proper schedule by working with staff and department leadership. Maintains the Utility Management Plan, the Statement of Conditions, and the Basic Building Information, utilities and construction committee incident reports, and trains staff on new and existing compliance requirements.

Essential Job Functions & Accountabilities:

• Responsible for all compliance documentation, including current inventories, testing schedules and results, and corrective maintenance history required for generators, fire pumps, fire/smoke dampers, emergency lighting, medical gas, room pressurization, and other systems as assigned.
• Maintains all department policies, the Statement of Conditions, Basic Building Information, ICRA/ILSM documentation, and conducts annual grounds inspections of all locations. Gathers and reports on all material to be presented during the quarterly utilities and construction committee meetings.
• Develops general compliance educational activities, researches and interprets new codes in order to inform staff of new and existing requirements and to prepare for upcoming surveys.
• Serves as a key department representative with regulatory agency representatives, collecting content and providing presentation materials for review.
• Works with division leaders in the implementation of Compliance policies throughout JPS Health Network. Includes participating on workgroups, task groups, tracking milestones of implementation and development, research, or engagement of required educational needs assessment.
• Interacts with outside vendors and key customers to ensure all projects, required documents, and other forms of transaction based interactions are appropriately managed and met.
• Maintains up-to-date knowledge of CMS, Medicare/Medicaid, and Office of the Inspector General regulations regarding existing and emerging required testing, inspection, and documentation.
• Prepares initial drafts of various reports to senior management, including, but not limited to reports to the Board of Directors, Senior Leadership Team, Executive Leadership team and Board of Managers. Prepares materials/handouts for various compliance and privacy workgroups or meetings, including operating rooms, isolation rooms, and sterile processing reports of temperature, humidity, and room pressures, and tracks to ensure that life safety preventative and corrective maintenance work orders are completed on time.
• Maintains up-to-date communication efforts related to the Accreditation Program. This person will work with the Learning Institute and Clinical Education department in maintaining current and up to date required educational objectives and knowledge base as defined by regulatory mandates.
• Job description is not an all-inclusive list of duties and may be subject to change with or without notice. Staff are expected to perform other duties as assigned.

Required Qualifications:

• Certified Healthcare Safety Professional (CHSP) Certification OR Certified Healthcare Facility Manager Certification (CHFM).
• 7 years working in an administrative or clinical role, or performing Regulatory Compliance and/or Legal functions.
• 1 years working in a healthcare setting.

Preferred Qualifications:

• Bachelor’s degree in related field.
• 5 years healthcare compliance and/or accreditation experience.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• In-person

Work Location: In person