Director of Nursing Policy, Standards and Accreditation

LUX Infusion

1d•Remote

About The Position

At LUX Infusion, we’re reimagining infusion care to be more human, supportive, and connected. Inspired by lux—meaning light - we guide patients, providers, and partners through complex therapies with clarity, compassion, and confidence. As a clinician-led, U.S.-based organization, we put people first - helping patients feel seen and supported through faster therapy starts, dedicated care coordination, and meaningful collaboration. Our commitment to inclusion, diversity, equity, and advancement (IDEA) is central to our culture, ensuring every team member feels valued and empowered to make a difference. Company Overview: LUX Infusion is a nationwide, independently-owned infusion company with decades of experience supporting patients on specialty medication. Our compassionate care team helps patients navigate the often-challenging healthcare environment. We treat our patients like family and get them started on therapy quickly. We work closely with them as well as their family and their healthcare providers throughout the patient journey, staying focused on optimal clinical outcomes. At LUX Infusion the heart of our Inclusion, Diversity, Equity, & Access (IDEA) philosophy is the commitment to cultivate a welcoming space where everyone’s contributions are acknowledged and celebrated. Our goal is to draw in, develop, engage, and retain talented, high-performing individuals from diverse backgrounds and viewpoints. We believe that both respecting and embracing diversity enriches the experiences and successes of our patients, employees, and partners. Location & Travel: It is anticipated that an incumbent in this role will work remotely within the continental United States with up to 40% annual travel required. Status and location of position subject to change based on business needs. Job Description: The Director of Nursing Policy, Standards, and Accreditation is responsible for ensuring all company ambulatory infusion centers (AICs), ambulatory infusion suites (AIS’s) and home infusion nursing maintain continuous compliance with all applicable nursing accreditation and regulatory standards. This role oversees audit readiness at all times, coordinates accreditation activities, and collaborates closely with nursing operations leadership to ensure standards are integrated into daily operations. The Director is responsible for Nursing standards and primary responsibilities include participating in the standards development/revision process, conducting regular site visits, providing educational instruction through standards workshops, manage nursing policy and procedure and serve as the company’s subject matter expert in nursing accreditation compliance. This position supports accreditation services staff in completing scheduled work on time in accordance with LUX Infusion policies and procedures Director of Nursing Policy, Standards, and Accreditation is an integral contributor in providing strategic oversight for all accreditation, policy and quality services. This includes participation in monitoring, evaluating, suggesting and implementing needed changes and continuous quality improvement. Provides clinical guidance to management and operational leadership, with responsibility for oversight of the Performance Improvement and Quality Management Committee Program.

Requirements

Current, unrestricted Registered Nurse (RN) license (multi-state/compact preferred)
Bachelor of Science in Nursing (BSN) required
A minimum of five (5) years of experience in a healthcare organization with quality, compliance, and accreditation leadership required
Minimum of three (3) years of administrative experience developing and writing accredited applications and policies required
Demonstrated experience managing multi-site accreditation efforts and maintaining continuous audit readiness.
Has a deep knowledge of and experience with ACHC and/or URAC standards.
Strong knowledge of state and federal nursing regulations.
Excellent verbal, written, and presentation skills.
Operational or clinical experience with ambulatory infusion centers (AIC’s), ambulatory infusion suites (AIS’s), Home Health Care services.
Strong knowledge of state and federal nursing and healthcare regulations
Experience with clinical quality programs and performance improvement initiatives
Experience providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.
Requires problem solving, judgment and/or research to carry out complex procedures and/or recommend courses of action where no precedents or policies exist.
Intermediate level skill in Microsoft Office (including Word, Excel, PowerPoint, etc.).
Strong leadership presence with the ability to inspire confidence, foster trust, and serve as an approachable resource to staff at all levels.
Demonstrated consultative style, with the ability to guide cross-functional teams, influence stakeholders, and drive alignment on complex issues.
Exceptional interpersonal and communication skills, including the ability to present ideas clearly, listen actively, and adapt style to diverse audiences.
Proven ability to build and maintain collaborative partnerships, both internally and externally, to achieve organizational goals.
Skilled at managing through ambiguity, balancing competing priorities, and facilitating consensus in fast-paced environments.
High emotional intelligence, with a focus on empathy, integrity, and the ability to cultivate a positive organizational culture.
Knowledge of nursing, drug, and related laws of the state along with prescription monitoring programs.
Knowledge of the basic sciences underlying nursing, such as anatomy, biology, and physics.
Knowledge of accreditation requirements and process, ability to write and implement policies and procedures..
Ability to apply safety and efficiency in the prescribing, dispensing, administering, and use of drugs and related articles for the prevention of illness and the maintenance and management of health.
Ability to analyze and understand Physicians' or other recognized, medical personnel's oral or written orders involving standard symbols and terminology.
Ability to maintain accurate records and prepare reports and correspondence related to the work.
Ability to oversee nursing operations of multiple branch locations.
Advanced reasoning, analysis, language ability (reading, writing and speaking)
Ability to handle conflict and to exercise sound judgment.
Ability to think and act strategically and proactively.
Ability to maintain favorable public relations.
Ability to organize and coordinate the work of others.
Ability to set priorities and assign work to other professionals.
Excellent analytical skill.
Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
Become and remain proficient is all programs necessary for execution.

Nice To Haves

MSN or advanced degree preferred
Strongly preferred experience with NICA and ACHC accreditation
Experience with other accrediting bodies such as Joint Commission, NABP, etc. preferred
Experience at director or manager level in the infusion and/or specialty pharmacy, ambulatory infusion center or suite, or home care industry preferred
Masters or other advanced degree preferred
Experience and a strong knowledge base in infusion therapies i.e. chronic, specialty, and acute therapies

Responsibilities

Ensuring all company ambulatory infusion centers (AICs), ambulatory infusion suites (AIS’s) and home infusion nursing maintain continuous compliance with all applicable nursing accreditation and regulatory standards.
Overseeing audit readiness at all times.
Coordinating accreditation activities.
Collaborating closely with nursing operations leadership to ensure standards are integrated into daily operations.
Participating in the standards development/revision process.
Conducting regular site visits.
Providing educational instruction through standards workshops.
Managing nursing policy and procedure.
Serving as the company’s subject matter expert in nursing accreditation compliance.
Supporting accreditation services staff in completing scheduled work on time in accordance with LUX Infusion policies and procedures.
Providing strategic oversight for all accreditation, policy and quality services.
Monitoring, evaluating, suggesting and implementing needed changes and continuous quality improvement.
Providing clinical guidance to management and operational leadership.
Overseeing the Performance Improvement and Quality Management Committee Program.
Serve as the primary accreditation lead for all applicable nursing accreditation programs.
Develop and deliver workshops for facilities, programs, and site visitors.
Oversee accreditation services staff to update documents (applications, worksheets, accreditation manual, policy manual).
Review and implementation of Accreditation Standards.
Serve as the primary point of contact for assigned applications.
Communication with applicants utilizing positive customer relation skills.
Analyze applicants’ submitted documentation utilizing accreditation scoring methodology to determine eligibility for proceeding with the accreditation processes and issues written in the Desktop Review Summaries to the applicants.
Discuss the findings with the applicants and LUX Infusion in an educational manner.
Draft and submit written executive summaries and present the findings to the Accreditation Committees and LUX Infusion.
Conduct required follow-up activities of applicants such as onsite reviews.
Report any delay in the timely processing of applications to the Compliance and Privacy Officer as well as Senior Vice President of Nursing.
Assist in providing technical support and advice to accrediting bodies and Standards Committees.
Participate in Nursing standards development/revision process for the specific program.
Partner with Nursing and Ambulatory Infusion Center/Suites leaders to embed accreditation requirements into standard workflows.
Lead the development, maintenance, and approval process for all nursing-related policies and procedures.
Manage accreditation and policy/procedure integration during new mergers or acquisitions, ensuring seamless compliance alignment.
Plan, prepare, and lead internal audits and mock surveys; develop and oversee corrective action plans.
Conduct regular on-site visits to locations to verify compliance and provide operational support.
Act as the primary liaison with accrediting organizations, responding to inquiries, preparing required documentation, and coordinating site surveys.
Oversee Performance Improvement/Quality Management initiatives related to accreditation compliance.
Provide regular reports to the Compliance & Privacy Officer on accreditation status, identified risks, and improvement initiatives.
Oversee AIC and Nursing Accreditation Specialist(s) and Quality Specialist(s).
Collaborate with interdisciplinary teams including physicians, pharmacists, and administrators.
Able to communicate effectively and work collaboratively with other healthcare professionals, clients and other stakeholders.
Participation in membership in professional societies and organizations.
Ability to prioritize and handle multiple tasks and projects concurrently.
Must have scheduling flexibility and be able to work overtime and on-call coverage.
Overnight travel by car and airplane.
Performs related duties as requested.
Participates in quality assurance activities and audits as directed.