Corporate Infection Control Manager

POSITION SUMMARY:

The Corporate Infection Prevention Manager provides enterprise-wide leadership for infection prevention and control (IPC) across Nexus Health Systems. This role establishes, maintains, and continuously improves the enterprise infection prevention program in alignment with CMS Conditions of Participation, DNV NIAHO, The Joint Commission, CARF, Texas Administrative Code, CDC guidelines, and applicable state and local public health requirements. The Manager directs surveillance of healthcare-associated infections (HAIs), leads outbreak investigations, oversees hand hygiene and isolation practice compliance, serves as subject matter expert for construction and environmental risk assessments, and partners with Facility leadership and the Quality and Patient Safety team to embed IPC into clinical workflow and education. The Manager is deployed through the shared services operating model and may serve as the primary IPC contact for assigned facilities while retaining enterprise accountability.

JOB-SPECIFIC RESPONSIBILITIES:

•    Service 

o    Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems

o    Upholds the Standards of conduct and corporate compliance

o    Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.

o    Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.

o    Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

o    Collaborates effectively with colleagues and other departments to ensure seamless service delivery.

•    Clinical Excellence 

o    Design, implement, and sustain the enterprise infection prevention and control program in alignment with CMS, DNV, Joint Commission, CDC guidelines, and Texas Administrative Code requirements.

o    Direct enterprise surveillance of healthcare-associated infections (HAIs), including but not limited to central-line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated events (VAE), Clostridioides difficile infection (CDI), and multi-drug resistant organism (MDRO) surveillance.

o    Lead outbreak investigation, containment, and reporting in partnership with facility leadership, public health authorities, and the Corporate Director of Quality and Patient Safety.

o    Oversee hand hygiene monitoring, compliance reporting, and improvement initiatives across all facilities.

o    Direct isolation precaution practice standardization, including standard, contact, droplet, and airborne precautions, appropriate to population served.

o    Lead infection control risk assessments for construction, renovation, and environmental changes.

o    Serve as enterprise subject matter expert on emerging infectious disease response and pandemic preparedness.

o    Partner with the Corporate Clinical Practice Integration Specialist to translate IPC evidence and findings into standardized bedside practice and education.

o    Partner with the Corporate Director of Clinical Education to embed IPC content into onboarding, annual training, and role-specific competencies.

o    Apply Plan-Do-Check-Act methodology to infection prevention process design and sustainment.

o    Represent Nexus Health Systems in external public health partnerships and regulatory surveys as related to infection prevention.

•    Patient Experience and Advocacy 

o    Advocate for patient safety through infection prevention practice at the bedside.

o    Ensure IPC practices address population-specific vulnerabilities, including immunocompromised patients, pediatric populations, and patients with tracheostomy, ventilator dependence, or complex medical needs.

o    Support patient and family education on infection prevention in partnership with clinical teams.

•    Quality Assurance and Compliance 

o    Ensures all activities adhere to healthcare regulations and organizational policies.

o    Participates in quality improvement initiatives to enhance service delivery.

o    Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.

o    Serve as IPC subject matter expert for accreditation surveys, regulatory inspections, and public health inquiries.

o    Partner with the Corporate Director of Compliance and Risk Management on mandated infection reporting, HAI disclosure obligations, and regulatory response.

o    Submit required infection surveillance data to NHSN, CMS, and state agencies within required timeframes.

o    Maintain audit-ready documentation of surveillance, outbreak investigation, and IPC program activities.

o    Participate in enterprise Quality and Patient Safety Committee meetings and the Quality Council.

•    Professional Growth and Continuing Education

o    Completes annual education requirements.

o    Maintains competency, as evidenced by completion of competency validation requirements.

o    Maintains competency and knowledge of current standards of practice, trends, and developments.

o    Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.

o    Pursue and maintain Certification in Infection Prevention and Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC).

o    Participate in national professional organizations including APIC (Association for Professionals in Infection Control and Epidemiology).

o    Stay current with emerging infectious disease science and evolving CDC guidance.

o    Mentor facility-assigned Infection Preventionists and clinical staff in IPC practice.

•    Finance

o    Promotes stewardship of hospital resources while ensuring quality patient care.

o    Demonstrate return on investment through reduction in preventable HAIs and associated costs.

o    Support enterprise cost avoidance through effective outbreak containment and pandemic preparedness.

o    Optimize IPC resources through standardized methodology and shared services deployment.

Performs other duties as assigned. 

POSITION QUALIFICATIONS:

EDUCATION: 

•    Bachelor's degree required in Nursing (BSN), Public Health (BSPH), Epidemiology, Medical Technology / Clinical Laboratory Science, or related healthcare field, required.

•    Master of Science in Nursing (MSN), Master of Public Health (MPH), or Master's degree in Epidemiology or related field preferred.

EXPERIENCE: 

•    Minimum of 5 years progressive healthcare experience required.

•    Minimum of 3 years in infection prevention and control required.

•    Experience with NHSN reporting required. 

•    Multi-site or complex population experience preferred. 

•    Outbreak investigation experience strongly preferred.

SKILLS:

•    Expertise in infection prevention science, surveillance methodology, and healthcare epidemiology.

•    Working knowledge of CMS Conditions of Participation IC, DNV IC, Joint Commission IC, and Texas Administrative Code IPC requirements.

•    Proficiency in CDC guidelines for isolation precautions, hand hygiene, environmental cleaning, and transmission-based precautions.

•    NHSN reporting proficiency including protocol-specific surveillance definitions.

•    Application of Plan-Do-Check-Act methodology to IPC program design.

•    Outbreak investigation methodology and public health partnership skills.

•    Ability to communicate IPC science to clinical, operational, and executive audiences.

•    Excellent communication, critical thinking, and interpersonal skills.

LICENSURE/CERTIFICATION:  

•    Current unrestricted Registered Nurse (RN) license in the State of Texas preferred.

•    Master of Public Health (MPH) or equivalent public health / epidemiology credential accepted as alternative to RN licensure.

•    Certification in Infection Prevention and Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC) preferred.

•    BLS (Basic Life Support) from American Heart Association/American Red Cross required, must be valid for a minimum of 6 months from date of hire.

•    Must maintain current certification in good standing during employment with this facility.