Life Safety Regulatory & Reporting Specialist

Children's Hospital and Health System • Milwaukee, WI

8h

About The Position

Ensures the organization's Life Safety compliance with regulatory standards in accordance with the Joint Commission, Centers for Medicare & Medicaid Services and other pertinent regulatory agencies. Serves as a liaison between process owners, key stakeholders and hospital councils/committees in an effort to ensure regulatory compliance and to promote patient safety and the use of evidence based clinical practice as appropriate.

Requirements

• Bachelor's Degree in business or related degree
• 2+ years managing Environment of Care and Life Safety compliance in a Hospital setting
• Experience with healthcare regulatory reporting requirements
• Firm understanding of the principles of the Environment of Care and Life Safety compliance in a hospital setting
• Working knowledge of the Joint Commission, Centers for Medicare & Medicaid Services and other regulatory standards, requirements and survey processes as it pertains to Environment of Care and Life Safety.
• Excellent interpersonal and communication skills to negotiate collaborative efforts with other departments and to implement patient safety standards and guidelines.
• Ability to problem solve, make independent decisions, formulate reports, perform statistical analysis and interpret data.
• A high level of analytical ability to resolve complex patient care problems, administrative problems and research issues.
• Knowledge of information systems and computer operations (including Windows, Excel, Access, Adobe Acrobat,) in a hospital environment.

Nice To Haves

• CHFM-Certified Healthcare Facility Manager - American Hospital Association preferred
• CHC-Certified in Healthcare Compliance - Compliance Certification Board preferred

Responsibilities

• Acts as an internal Life Safety consultant to provide current information regarding standards and survey processes across the enterprise.
• Analyzes data and identifies trends with Life Safety Compliance. Collaborates with others to mitigate failures on regulatory issues.
• Develops plans for compliance with new standards and addresses issues of non-compliance when they are identified.
• Leads the facilitation of the survey process including agenda, survey coordination, survey submission, post survey communication, development and submission of evidence of standards compliance (ESC) or equivalent documents.
• Coordinates and collaborates Life Safety issues and concerns with Patient Safety, Corporate Compliance, Risk Management, and key stakeholders on identified organizational risks that apply to the regulatory environment.
• Uses quality improvement methodologies, tools and statistical process control to facilitate improvements of systems and processes.
• Maintains data integrity of the compliance tracking software to ensure regulatory data is up to date and ensures data sources are consistent.
• Develops a structure through which there is a continual review of standards. Maintains calendar of activities including survey time periods and deadlines.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level