Life Safety Regulatory & Reporting Specialist

Job Title

At Children's Wisconsin, we believe kids deserve the best.

Children's Wisconsin is a nationally recognized health system dedicated solely to the health and well-being of children. We provide primary care, specialty care, urgent care, emergency care, community health services, foster and adoption services, child and family counseling, child advocacy services and family resource centers. Our reputation draws patients and families from around the country.

We offer a wide variety of rewarding career opportunities and are seeking individuals dedicated to helping us achieve our vision of the healthiest kids in the country. If you want to work for an organization that makes a difference for children and families, and encourages you to be at your best every day, please apply today.

Job Summary

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.

Essential Functions

• 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.

Education

Bachelor's Degree in business or related degree Required

Experience

2+ years managing Environment of Care and Life Safety compliance in a Hospital setting Required - Experience with healthcare regulatory reporting requirements Preferred

Knowledge, Skills and Abilities

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.

Licenses and Certifications

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

Required for All Jobs

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that may be requested in the performance of this job. Employment is at-will. This document does not create an employment contract, implied or otherwise.

Children's Wisconsin is an equal opportunity / affirmative action employer. We are committed to creating a diverse and inclusive environment for all employees. We treat everyone with dignity, respect, and fairness. We do not discriminate against any person on the basis of race, color, religion, sex, gender, gender identity and/or expression, sexual orientation, national origin, age, disability, veteran status, or any other status or condition protected by the law.