• Regulatory Compliance Director

    Location US
    Job ID
    Company Name
    Medxcel Facilities Management
  • Overview

    The Regulatory Compliance Director provides expert consultation, education and technical assistance to Medxcel operations and ministry hospitals in complying with the Authority Having Jurisdiction (AHJ) Standards and Programs.  AHJ’s to include: the Joint Commission (TJC)-Physical Environment (PE), CMS-Conditions of Participation, OSHA, States Department of Health, etc. This position will provide regulatory guidance to Survey/Start-Up Teams, Medxcel FM-Safety and Facility Operations Teams.


    The Regulatory Compliance Director will utilize Medxcel's tools to conduct: Mock Surveys, Tracer Reviews, and assessing Standards compliance. The position will provide the regulatory expertise in supporting Medxcel FM’s - Facility Management Operating Systems (FMOS), assessing new and existing business for regulatory compliance, and provide input into Medxcel's Monthly Newsletter concerning Compliance Excellence. The position supports the sales process by assisting with PE/FM compliance analyses in the development of sales proposals.


    Leadership, Coaching and Development:

    • A keen business acumen with the ability to effectively influence and collaborate with stakeholders of all levels (frontline to C-Suite) within ministry/client organizations
    • Provide strong leadership particularly in the areas of patient safety, patient experience, regulatory compliance, risk reduction, performance metrics, work process efficacy and efficiency, team performance, and the pursuit of excellence utilizing Medxcel Programs
    • Facilitates the creation of a professional practice environment that promotes excellence in patient centered care and provides for positive patient outcomes
    • Provide leadership and direction for TJC accreditation process and ensure compliance with other regulatory requirements
    • Facilitates and promotes organizational regulatory readiness and compliance according to the requirements of the AHJ
    • Provide guidance to teams for program creation and delivery
    • Work effectively with Medxcel executives and other leaders to drive business innovation, service strategies, revenue growth, and continuous improvement processes at the regional level to ensure service excellence
    • Leverage local and regional professional society involvement as a means of promoting and representing Medxcel within regions or local communities through pre-defined branding and service initiatives


    Operational Support Management:

    • Ensure regulatory updates from TJC, CMS and State Department of Health are disseminated to leaders and teams appropriately
    • Provide education and training to Executive and Clinical Leadership concerning changes in requirements for accreditation and licensure
    • Evaluate the effectiveness of quality programs/processes against standards of practice, protocols, and patient outcome measurements
    • Create action plans to ensure regulatory compliance for new and existing Medxcel business units
    • Work with the National Director of Program Management to transition Medxcel’s policies and operational procedures to hospital associates
    • Provide support for corporate wide and regional strategic initiatives as assigned
    • Support the sales process by assisting with operational and regulatory analyses, and by providing technical support in the development of service proposals
    • Fully accountable for achieving service excellence, regulatory compliance, and organizational development goals
    • Create a high performing team of on-site leaders through selecting and retaining the best individuals possible and appropriately holding this team accountable for their areas of responsibility


    Compliance Management:

    • In collaboration with the National Director, Program Management-Facilities, provide oversight and direction to the Physical Environment program
    • Provide support to client organizations in reviewing complaints from the state and/or federal government and advising organizations accordingly
    • Requires the ability to develop an action plan as a result of deficiencies cited due to a complaint, focus or validation survey
    • Perform mock surveys, Tracer Reviews, Life Safety and Safety Assessments of healthcare facilities as part of the compliance process
    • Develop action plans to re-mediate issues identified as areas of improvement
    • Perform in-depth quality reviews of site operations using the tools provided by Medxcel Facilities
    • Facilitate on-going plans, goals, and objectives, to correct deficiencies and improve performance
    • Lead the team of on-site associates emphasizing the compliance of Medxcel’s operational program, FMOS, to enable on-site leaders to succeed


    Education and Work Experience:

    • Bachelor’s degree in business, engineering, or management required (or equivalent experience of 15 years with no degree)
    • MBA and graduate degree preferred
    • Ten or more years of recent experience in health care, with seven to ten years of progressively increased responsible experience in senior healthcare management or demonstrated consulting expertise
    • Experience in deploying service programs is preferred
    • Experience with the Joint Commission’s Physical Environment and CMS’s Conditions of Participation
    • Experience with NFPA 101 Life Safety Code and other National Fire Protection Agency (NFPA) requirements
    • Certified Healthcare Facilities Manager (CHFM) and/or Certified Healthcare Safety Professional (CHSP) certification preferred
    • Project management skills including coordination, communication, prioritization, troubleshooting, adherence to budget and completion goals, and recruiting resources
    • Travel: 60 - 80% (overnight required)


    • Strategic leadership skills to execute initiatives and objectives
    • Problem solving—identifies and resolves problems in a timely manner, gathers and analyses information skillfully
    • Planning/organizing—prioritizes and plans work activities, uses time efficiently and develops realistic action plans
    • Has the ability to clearly link deficient practices with related CMS regulations and TJC standards with potential system vulnerabilities and related organization risk points
    • Ability to adapt –will need to adapt quickly to changes in scope or direction and be flexible to adopting changes quickly
    • Excellent communication and interpersonal skills with ability to communicate across all levels of the organization, including technology, tools, and processes
    • Experience and proficiency with MS Office Suite
    • Excellent leadership skills, including the leading of other high performing leader/managers
    • Working knowledge of hospital FM operations and hierarchy of leadership
    • Working knowledge of facility systems and equipment
    • Negotiation skills



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