Joint Commission Compliance Manager

Job Description

General Summary

Maintain thorough understanding of, and comply with, the most recent standards established by applicable accrediting Authorities Having Jurisdiction (AHJ) such as the Joint Commission (TJC), The Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC), The College of American Pathologists (CAP), The American Association of Blood Banks (AABB), etc., as well as other applicable industry medical codes and standards governing the operation of a medical facility.

Essential Duties and Responsibilities

Record and maintain documentation to validate compliance with these codes and standards.

Remain abreast of any changes which impact facilities and ensure that all work supports any changes made by the AHJ.

Prepare and submit an Accreditation Compliance and Documentation Plan for Government review and approval.

Develop and submit an Environment of Care (EC) Policy and Procedures Manual addressing all training and record keeping for documentation of employee competency.

Satisfy requirements of the EC Standards relating to utility systems and all other building systems (fire safety equipment, emergency power systems, medical gas and vacuum systems, HVAC, EMCS, etc.).

Maintain management program that is used to identify and document utility problems, failures, and user errors that are or may be a threat to the patient care environment.

Participate in activities of the medical treatment facility (MTF) that are designed to meet the requirements of TJC pertaining to Process Improvement (PI) programs (including PI monitors, data collection, report preparation, and presentation).

Conduct quarterly in-process, line item reviews of program

Other duties as assigned.

Knowledge, Experience and Skill Requirements

Certified Healthcare Facility Manager (CHFM) Certification required

Minimum of two (2) years’ experience with The Joint Commission compliance (maintenance and documentation, including all DMLSS work requests and all supporting testing/certification/verification requirement)

Working knowledge of applicable related codes and standards such as NFPA, ADA, ABA, Unified Facilities Criteria, ASHRAE,

Working knowledge of The Joint Commission Life Safety and Environment of Care

standards, to include experience working with submitting and managing reports such as the Electronic Statement Of Conditions (e-SOC)

Work Environment

Works in office areas as well as throughout the facility.

Physical demands include intermittent sitting, standing, and walking, and occasional bending reaching and lifting.

Limited exposure to elements such as heat, cold, noise, dust, dirt, chemicals, etc. but generally not to the point of being disagreeable.

This job description is subject to change by the employer as the needs of the employer and requirements of the job change.

We maintain a drug-free workplace and perform pre-employment substance abuse testing.