Full-Time Internal Auditor & Life Safety Specialist-8030

Job Description

Staff Position Description

Position Title: Internal Auditor / Life Safety Specialist Position Code: SpecIntAud-8030

Department: Quality Safety Sensitive: Yes

Reports to: Internal Audit Manager Exempt Status: Yes

Position Purpose:

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision of providing the region’s best clinical care and patient service through an environment that fosters respect for others and pride in performance.

The Internal Auditor / Life Safety Specialist is responsible for ensuring support and compliance with KHI’s Quality Management System and the Internal Audit Program by facilitating Environment of Care / Life Safety surveys, internal quality audits, and continual process improvement. Reporting to the Internal Audit Manager, the Internal Auditor / Life Safety Specialist is responsible for coordination, implementation, and documentation of regulatory-based Environment of Care / Life Safety rounds for KHI’s various internal and external departments and facilities throughout the community. The Internal Auditor / Life Safety Specialist will manage these processes according to the requirements of the applicable regulatory agencies, federal, state, and local law, and statutes.

The Internal Auditor / Life Safety Specialist will also collaboratively work with the Internal Audit Manager to develop and conduct internal audits, lead and supervise internal audit teams in accordance with DNV-GL and ISO ideologies, report findings to the Internal Audit Manager, and collaborate with the Internal Audit Oversight Committee. The Internal Auditor / Life Safety Specialist will be involved in the re-audit process to validate effective corrective action and continual improvement process.

Key Responsibilities [List of material responsibilities and essentials duties which must be completed in achieving the objectives of the position]

· Coordination, management, and documentation of regulatory based Environment of Care / Life Safety audits utilizing a multi-disciplinary collaboration with internal and external colleagues, surveyors, and inspectors.

· Knowledge of regulatory requirements: Centers for Medicare and Medicaid Services (CMS), DNV-GL Health Care, National Fire Protection Association (NFPA), Occupational Safety and Health Administration (OSHA), and other federal, state, and local regulatory agencies.

· Prepare post audit reports to be disseminated to the site Manager/Director and Senior Leadership. Monitor corrective action plans for effectiveness and sustainability.

· Develop and present post audit trending data to specified committees and stakeholders.

· Educate management and hospital staff regarding the Life Safety requirements as stated by the NFPA, DNV-GL HC accreditation process, ISO 9001 certification, the Quality Management System, and auditing processes.

· Participate in development and implementation of additional Environment of Care / Life Safety activities.

· Assist and coach corrective action plans.

· Facilitate process improvement projects.

· Ensure maintenance and sustainability of corrective action plan improvements.

Qualifications [Statements regarding minimum educational and experience qualifications, required proficiencies with specialized knowledge, computer proficiencies, military service, required certifications, etc.]

Education: Associates degree or equivalent combination of education and experience.

Certification:

National Fire Protection Association (NFPA) Certified Life Safety Specialist (CLSS-HC) and

DNV-GL Internal Auditor Training Course within 1 year of hire.

Experience: Minimum of three (3) years of experience in a healthcare/hospital setting.

Skills and Knowledge: Knowledgeable regarding CMS, National Integrated Accreditation for Healthcare Organization (NIAHO), NFPA and ISO 9001 requirements.

Preferences [Preferred attributes for the position which are not absolutely required in the minimum qualifications (i.e., multi-lingual, master’s degree)]

Education: Bachelor’s Degree in a healthcare related field

Special Position Requirements [Optional section: any travel, security, risk, hazard or related special conditions which apply to the position]

Blood Borne Exposure Category I: Expected duties have routine potential for exposure to blood, body fluids,

or tissues.

Work Requirements [Optional section: work requirements for physical or other important issues which relate to the job]

· Ability to move freely about the hospital to perform designated duties for up to 8 hours (full scheduled shift).
Ability to sit at a computer for up to eight hours a day.

· Ability to lift, up to 25 pounds.

· Ability to efficiently and effectively use technological resources (computer, internet, tablets, laptops, phones, etc.).

· Visual acuity in multiple settings (desktop, technological resources, patient rooms, business offices, commercial storage areas, and general building facilities).

· Ability to effectively manage processes and exercise effective judgment in the implementation of programs and services.

· Ability to effectively and positively communicate in a variety of settings with a variety of customers, including ability to analyze and interpret data to produce concise, accurate reports.

· Ability to effectively manage interpersonal relationships with both internal and external customers.

Date Staff Position Description Created / Revised: 10/28/2019; 5/20/2021

Posting Date: 2025-01-14T00:39:23 00:00

Locations: 3269 Stockton Hill Road Kingman AZ 86409