Job Description

As a Facilities Compliance Specialist in a large healthcare system, you will play a crucial role in ensuring safety and compliance of our facilities with various regulatory bodies, including The Joint Commission, NFPA, OSHA, ADA, and CMS. The primary responsibility of this position is to help maintain a safe environment and to ensure constant state of compliance with regulatory requirements. This may involve daily inspections, coordination of fire safety measures, overseeing documentation compliance, and contributing to the overall safety and well-being of patients, visitors, and employees.

In-depth conceptual and working knowledge in job area; familiarity in related disciplines / specialties. Requires minimal guidance, may lead projects of manageable risk or have accountability for ongoing activities or objectives. Deep experience in role; able to train / may lead others in job area. Executes wide range of difficult / complex tasks Level at which career may stabilize.

Regulatory Compliance & Oversight:

• Actively participate in inspections and surveys when The Joint Commission, ODH, State Fire Marshal, or other regulatory agencies are onsite.
• Perform regular reviews of Environment of Care (EC) and Life Safety (LS) documentation for the healthcare system.
• Independently Analyze and interpret regulations from The Joint Commission, NFPA, OSHA, ADA, EPA, and CMS to ensure regulatory compliance.
• Assist with the System EOC Committee- participate in monthly meetings, provide updates on compliance status for all sites, assist with annual revisions of EOC

Management plans and Annual Evaluations.

• Create, revise, and implement policies and SOPs relating to facility compliance.
• Serve as an institutional content area expert in assigned program area related to facilities compliance/oversight.
• Serve as key resource in the development, oversight, management, and record keeping aspects of assigned program area.

Daily Rounding and Inspections:

• Conduct daily rounds and inspections of hospital departments to ensure a safe environment for patients, visitors, and employees.
• Identify and address potential safety hazards and compliance issues.

Fire Safety Oversight:

• Lead and coordinate fire extinguisher inspections.
• Organize and oversee fire drills, ensuring proper execution and documentation.
• Train and educate leaders to ensure proper implementation of interim life safety measures (ILSM).

Institutional Support:

• May be called upon to provide key input, based on knowledge, experience and expertise, on institutional initiatives and programs at the direction of leadership, to ensure compliance with applicable regulations/codes, and UC Health policies, principles, ethical standards, and procedures.
• May acquire and interpret maintenance data to determine operational status of plant equipment and systems at all UC Health sites.

Other Responsibilities as Required

Minimum Required: Associate's Degree.

Preferred: Bachelor's Degree in Engineering, Fire Science, or a related field.

Preferred Certification: Certified Healthcare Facility Manager (CHFM).

Minimum Required Experience: 6 to 10 years of relevant experience.

Preferred Experience: 11 to 15 years of relevant experience.

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is an EEO employer.