Ambulatory Surgery Center Compliance Manager
3 weeks ago
The Ambulatory Surgery Center Compliance Manager will be a role that will lead and oversee the management and operations of Ambulatory Surgery Centers including maintenance, repair, vendors and contracts, and other facility related operations for our healthcare clients. In addition, the Ambulatory Surgery Center Compliance Manager will ensure continuous survey readiness and compliance with Environment of Care (EC) and Life Safety (LS) requirements and regulations from a variety of regulatory agencies, including the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), National Fire Protection Association (NFPA), State Survey Agency (SA), and other Accrediting Organizations (AOs) for Ambulatory Surgery Centers (ASCs).
The Ambulatory Surgery Center Compliance Manager will apply sophisticated analysis and inductive reasoning skills to assess health care organizations' compliance with applicable standards, policies, and protocols, and to identify opportunities for improvement. The ideal candidate will have extensive expertise in property and/or facilities management within a healthcare setting, as well as extensive experience effectively communicating with clients, vendors, and co-workers. Exceptional leadership, problem-solving, and communication skills are also required.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Develops and maintains positive relationships with clients.
• Manage and organize the operations of the facility including preventative maintenance and general upkeep, while maintaining compliance with all applicable codes, standards of government, and regulatory agencies.
• Coordinates, oversees, and schedules inspections/repairs of maintenance work assignments performed by technicians, vendors and contractors performing Building Maintenance, Fire & Life Safety Inspections, HVAC Preventative Maintenance, Generator Preventive Maintenance, and Medical Equipment service.
• Manages vendor relationships and train vendors on work order and billing procedures.
• Responsible for work order review to ensure that assignments are completed.
• Responsible for reviewing vendor inspection reports to ensure all deficiencies are corrected in a timely manner.
• Responsible for invoice review and accuracy of cost related to work performed.
• Performs building inspections of properties within designated portfolio.
• Ability to self-manage and operate independently.
• Learn, understand, retain, explain, and objectively apply Accreditation standards, NFPA Standards including continual updating and retraining regarding Life Safety, Environment of Care, and Emergency Management standards and technologies.
• Responds effectively to all emergencies during normal and after-hours.
• Maintains information of all building equipment, building access, emergency contacts and vendor list.
• Maintains liaison with VP Managing Director of Engineering Department regarding work orders, job completion dates, priorities, and estimates.
• Maintains and organizes the documentation related to Environment of Care & Life Safety inspections performed by clients and/or vendors, within the Life Safety Compliance Book.
• Makes recommendations for systems improvement through immediate supervisor or management.
• Demonstrated customer service skills, including interpersonal skills related to effectively interacting with internal and external customers, sometimes in sensitive situations.
• Track operational savings by facility.
• This is a management position and will require oversight of assigned Flagship Engineers. This position is remote but requires traveling to facilities on a quarterly basis and office visits when requested by supervisor.
• Performs additional job duties as requested.
DOCUMENTION MANAGEMENT:
• Maintain and continuously improve the Environment of Care, Life Safety, and Emergency management plans ensuring compliance with regulatory standards and implementation at the ASC.
• Maintain regulatory readiness documentation, ensuring the facility is in compliance with regulatory standards and that any inspection deficiencies are corrected with proper documentation filed.
• Creating new Life Safety Compliance Books for new ASC locations.
EDUCATION & EXPERIENCE:
• Required – High School Diploma or General Education Degree (GED).
• Preferred - Bachelor's degree in related field.
• Preferred - Eight years of hospital or medical properties experience in facilities management.
• Preferred - Knowledge of Joint Commission Environment of Care standards including the Life Safety Code (NFPA101), the Health Care Facilities Code (NFPA 99), and other relevant NFPA standards and direct involvement with a minimum of two Joint Commission surveys.
• Specialized knowledge of building systems, utility systems, and fire protection systems (smoke detection and sprinklers).
CERTIFICATES, LICENSURE, REGISTRATIONS:
• Required – Clean/Valid driver’s license.
• Preferred – Completed OSHA 30 or 10 Training or able to attain within one year of hire.
• Certified Life Safety Specialist (CLSS-HC) for Health Care Facility Managers or able to attain within one year of hire.
• Certified Healthcare Facility Manager (CHFM) or able to attain within one year of hire.
PROFESSIONALISM, COMMUNICATION SKILLS:
• Dependability, including delivering on commitments, assuming appropriate share of all work, being prepared, and adhering to schedules.
• Requires extensive attention to detail.
• Professionalism, including appearance and demeanor.
• Communicate effectively, clearly, and professionally with tenants, management, co-workers, and vendors.
• Communicate via email with proper punctuation and spelling.
• Ability to comprehend and interpret instructions.
• Ability to write routine reports and correspondence.
COMPUTER, ORGANIZATIONAL SKILLS:
• Knowledge of CMMS (Computerized Maintenance Management System). Building Engines/PRISM – preferred.
• Working knowledge of Microsoft 365 programs.
• Working Knowledge of Adobe programs.
• Ability to independently organize work.
• Organizing files for multiple facilities.
• Demonstrate effective time management skills.
• Coordinate activities involving other people.
PHYSICAL ABILITIES:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. To stand for long periods of time, walking lengthy distances, lifting, climbing, stooping, pulling, kneeling, and pushing in order to adequately inspect and observe the entirety of the medical facilities.
•To lift, push and pull a minimum of 25 pounds.
•Able to climb a ladder, bend, twist, crawl, and jump.
•Able to fly commercial airlines.
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