Manager Compliance Support Services

Overview

Medxcel is here to lead the transformation of healthcare facilities management by incorporating a new approach to providing services. Created by healthcare, for healthcare, we have a dedicated focus on our people and customers, as well as providing tools, processes, support resources, data analytics and insource strategies that drive results.

The Manager Compliance Support Services leads a team responsible for data management, analysis, and operational support for regulatory agency survey preparation, regulatory compliance risk assessment, and survey response across multiple departments within Medxcel, Ascension, and other customer facilities. The Manager Compliance Support Services leads data-driven compliance efforts and operational excellence initiatives across Medxcel and Ascension facilities using data modeling and analysis techniques to strengthen sites for survey preparedness, guide strategic business decisions, and uncover organization optimization opportunities. It combines technical database management, process improvement, data analytics leadership, regulatory compliance, and cross-functional collaboration to support strategic decision-making and ensure continuous improvement in service delivery and survey readiness.

The Manager oversees the Facilities Management Operating System (FMOS™) policy and program updates, coordinating modifications with field operations to ensure survey readiness. This position oversees report development to support leadership in determining department operations requirements, survey scheduling, Validation and MEP assessments, and related training programs in support of survey readiness and response.

This position will be located at Medxcel- Central Office.

Responsibilities

• Partner with executives, commercial clients, and leaders to drive innovation, compliance and service strategies to ensure national survey readiness and service excellence using data analytics.
• Support and guide compliance related programs like FMOS™, Health Assessments, CMS/Data, and MEP Assessments that drive operational excellence.
• Oversee data analysis from compliance assessments (e.g., CSHA, TJC, Ascension Care Excellence).
• Build and maintain data models, dashboards, reporting systems, automation systems and provide performance metrics support for strategic decision-making.
• Review and approve final client reports and presentations for senior leadership.
• Provide regulatory and survey support through data support of validation assessments, Joint Commission surveys, preparation of post-survey analysis reports and enhancing related project documentation.
• Participate in committees and projects related to compliance, cost containment, and performance measurement, and service/system implementation.
• Manage and analyze data from the Current State Health Assessment (CSHA), The Joint Commission (TJC), Ascension Care Excellence, etc. for trends, benchmarking, improvement and training opportunities.
• Support a team of subject matter experts that provide data for Regulatory Compliance, Facility Start-Up, Strategic Resources, Program Management, Fire Safety Services and CMMS Operations support.
• Maintain and administer divisional support for Compliance and Safety and Emergency Management Share Point Sites.
• Support the Strategic Resource Team in developing and maintaining processes for entering POs in D365, monthly report outs for elevator spending, schedules, and projects.
• Assess data from MEP surveys for trends, opportunities, and improvements.
• Coordinate schedules, projects, and surveys for Resources Directors with other Medxcel and third-party companies; collaborate and coordinate projects between Resource Directors and Compliance Teams.
• Support Education and Training for Omega Training and Divisional Orientation including aligning compliance course to job codes and responding to regulatory or legal requests for training or compliance documentation.
• Manage day-to-day database operations ensuring integrity within CMMS used by Facilities Management including database support and maintenance, data gathering and documentation, related software projects, and reporting and analytics using CMMS tools and third-party software.
• Coordinate schedules, projects, and surveys for Resources Directors with compliance teams as well as other Medxcel teams and third-party companies.
• Recruit, train, develop, and supervise Compliance Support Service team members.
• Build commitment and drivess engagement by communicating goals, soliciting input and inspiring action through coaching and mentoring.

Qualifications

Education:

• Bachelor’s degree in Administration with emphasis in Business or Health Care Management OR 10+ years equivalent experience in lieu of degree- required.
• MBA or other graduate degree-preferred.

Experience:

• Five years’ experience working with Corporate Compliance Teams in a Healthcare Environment- required.
• Experience working with Facility/Compliance Operating Program- required.
• Experience working in the Healthcare Facilities Management industry-preferred.

Knowledge, Skills and Abilities:

• Knowledge of the Joint Commission’s Physical Environment Standards and Elements of Performance.
• Ability to perform postmortem AHJ survey analysis with reports for Medxcel FM Executive and Facilities Compliance Teams.
• Ability to collaborate with Accreditation Organizations.
• Excellent leadership skills, including ability to manage associates in a matrix reporting structure.
• Expert proficiency with Microsoft Office applications (MS Word, Excel, and PowerPoint), particularly Excel analysis and processing techniques.
• Excellent communication and interpersonal skills with ability to communicate across all levels of the organization, including technology, tools, processes, and presentation and facilitation skills.
• Decisive judgment – ability to assess situations or circumstances and draw sound and objective conclusions.
• Ability to Adapt – the individual will need to adapt quickly to changes in scope or direction and be flexible to adopting changes quickly.
• Accountability – ability to take responsibility for action and results.
• Problem solving - identify and resolve problems in a timely manner and gather and analyze information skillfully.
• Planning/organizing - prioritize and plan work activities, use time efficiently, and develop realistic action plans.
• Critical thinking skills – ability to gather, synthesize, analyze information to objectively draw conclusions, make reasonable decisions, and provide solutions and communicate the situation, action, and result clearly and concisely.
• Strategic thinking – ability to keep the big picture in mind while working with large amounts of data.
• Advanced analytical skills to create and work with the tools, data and metrics.
• Quality management - look for ways to improve and promote quality and demonstrate accuracy and thoroughness.
• Strong process creation and improvement skills.
• Ability to work effectively with other team members and other departments.

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