Quality Risk/ Infection Control Manager

Essential Functions

Program Development & Oversight

• Develops, implements, and annually evaluates the hospital’s Infection Prevention and Control Plan in alignment with facility goals, risk assessments, and TJC/CMS standards.
• Establishes and maintains policies and procedures for infection prevention and employee health related to communicable diseases and exposures.
• Conducts an annual infection control risk assessment based on population served, services provided, and environmental risks.

Surveillance and Data Reporting

• Conducts ongoing infection surveillance and monitors trends in healthcare-associated infections (HAIs) and communicable diseases across all hospital departments.
• Collects, analyzes, and reports infection data to leadership, the Quality Assurance Committee, and regulatory agencies as required.
• Investigates outbreaks and clusters of infection, determines sources, and implements corrective actions.
• Submits required reports to local and state health departments and participates in national or state reporting systems as applicable.

Education and Staff Training

• Develops and conducts initial and ongoing staff education on infection prevention and control, including hand hygiene, standard and transmission-based precautions, personal protective equipment (PPE), environmental cleaning, and bloodborne pathogen exposure prevention.
• Provides real-time coaching and feedback to staff during environmental rounds and infection control observations.
• Ensures annual competency validation related to infection prevention practices.

Performance Improvement

• Collaborates with the Quality and Safety Committee to identify infection prevention performance measures and improvement projects.
• Utilizes data-driven methods and evidence-based practices to develop and monitor Performance Improvement Plans (PIPs) targeting infection prevention outcomes.
• Participating in root cause analyses and sentinel event reviews related to infection control issues.

Occupational Health & Immunizations

• Monitors staff immunization compliance and exposure management (e.g., influenza, Hepatitis B, tuberculosis testing).
• Oversees influenza vaccination program for employees, volunteers, trainees, and contract personnel with patient contact, maintaining documentation and compliance reports.
• Ensures appropriate follow-up and documentation for staff exposure incidents (e.g., bloodborne pathogens, airborne exposures).

Environmental Rounds and Risk Management

• Conducts regular infection prevention rounds in clinical and non-clinical areas, ensuring compliance with hand hygiene, isolation procedures, environmental cleaning, and equipment disinfection.
• Partners with Environmental Services and Facilities to address environmental infection control issues, including construction/renovation risk assessments and water management.
• Ensures the implementation of interim life safety and infection prevention measures during construction and renovation projects.

Regulatory Compliance

• Maintains a thorough understanding of Joint Commission IC standards, CMS infection control regulations, and applicable state health department requirements.
• Prepares and maintains documentation for regulatory and accreditation surveys.
• Serves as a content expert and liaison during TJC, CMS, and state health department inspections.

Committee Participation

• Provides routine reports to the Quality and Patient Safety Committee.
• Collaborates with medical staff, nursing leadership, and other departments to ensure infection prevention integration across all hospital functions.

Minimum Qualifications

Education:

• Minimum: Associate Degree in Nursing (ADN)
• Preferred: Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing, Public Health, or related field

Experience:

• Minimum of three (3) years of experience as a Registered Nurse in an acute or behavioral healthcare setting.
• At least two (2) years of experience in infection prevention, employee health, or quality improvement preferred.
• Knowledge of surveillance systems, microbiology, epidemiology, and infection prevention practices required.

Licensure / Certification:

• Current and unrestricted RN license in the state of practice.
• Basic Life Support (BLS) certification required.
• Infection Control Certification through American Health Training is required
• Certification in Infection Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC) preferred
• CPI (Crisis Prevention Intervention) certification within 90 days of hire.

Additional Requirements

• Demonstrates working knowledge of Infection Control Standards (TJC IC Chapter) and CMS Condition of Participation §482.42 (Infection Control Program).
• Maintains confidentiality and compliance with HIPAA and hospital policies.
• Participates in emergency preparedness and pandemic response activities.
• Assists with floor nursing as assigned, within scope of infection control responsibilities.
• Participates in hospital-wide committees as assigned.

Employee Acknowledgment
I have reviewed and received a copy of the Infection Control Nurse Job Description. I understand this description outlines general duties and that additional related duties may be assigned as necessary for the hospital’s operation and compliance.

Licenses & Certifications

Preferred

• Registered Nurse
• Licensed Practical Nurse

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.