Quality, Risk, And Infection Prevention Manager

Surgery Partners • Durango, CO

117d • Onsite

About The Position

The Quality, Risk, and Infection Prevention Manager is responsible for developing, implementing, and maintaining comprehensive quality monitoring and reporting, risk management, and infection prevention strategies across the organization. This position ensures compliance with regulatory standards and industry best practices, promotes a culture of safety, and provides leadership and direction to effectively manage and mitigate organizational risks.

Requirements

• Bachelor's degree in Nursing, Public Health, Healthcare Administration, or a related field required.
• Master's degree in Healthcare Administration, Nursing, Public Health, or a related field preferred.
• Minimum of 3 years of experience in Healthcare Administration, Nursing, Public Health, or a related field.
• Demonstrated leadership experience, including facilitation of meetings, closed loop communication and follow-up, and program development.
• Current state license as a registered nurse; current CPR certification; ACLS, PALS or TNCC certifications per policy.
• Knowledge of healthcare regulations, accreditation standards (e.g., Joint Commission), and guidelines (e.g., CDC, OSHA).
• Strong analytical and problem-solving skills with a proven ability to interpret data and metrics.
• Excellent communication, presentation, and interpersonal skills to effectively engage various stakeholders.
• Ability to manage multiple priorities, work under pressure, and adapt to a rapidly changing environment.
• Proficiency in Microsoft Office Suite and data analysis tools.

Responsibilities

• Analyze performance data and assigned quality measures.
• Identify trends, gaps, and opportunities and evaluate the need for quality improvement initiatives, policies, and procedures in line with regulatory requirements and organizational goals.
• Collaborate with cross-functional teams to implement process improvements that enhance patient care, operational efficiency, and service quality.
• Lead and facilitate quality committees or workgroups, ensuring consistent application of quality standards throughout the organization.
• Monitor and evaluate the enterprise-wide risk management program in partnership with the Quality Director to identify organizational risk.
• Analyze incident reports and partner with hospital leadership for timely follow up and closure of events.
• Monitor for trends in events related to processes and individuals for potential quality improvement initiatives.
• Investigate adverse events to determine root causes and develop corrective action plans.
• Educate staff on risk prevention strategies, regulatory requirements, and best practices to promote a proactive culture of safety.
• Review patient complaints and evaluate the need to escalate to a grievance according to CMS definitions.
• Draft and respond to identified grievances according to hospital policy.
• Facilitate the review of grievances at the assigned hospital committee.
• Coordinate with legal, claims and insurance regarding high-risk events.
• Establish, implement, and monitor infection prevention and control policies and procedures to minimize the spread of infectious diseases.
• Lead organizational compliance with infection prevention guidelines from relevant agencies (e.g., CDC, WHO, OSHA, The Joint Commission).
• Conduct regular infection control surveillance, audits, and risk assessments to identify areas for improvement.
• Provide routine follow-up to identified areas for opportunity to ensure compliance with action plans.
• Provide guidance and expertise during outbreaks or infection-related emergencies, ensuring appropriate containment and mitigation measures are in place.
• Partner with departmental leaders to investigate and report hospital acquired conditions (e.g., SSI's, CAUTI, CLASBSI, Emerging Infections).
• Submit required data to NHSN and ensure accurate public reporting of healthcare-associated infections.
• Review and coordinate employee health follow up in alignment with OSHA and CDC guidance.
• Stay current with healthcare regulations, accreditation standards, and applicable laws related to quality, risk, and infection prevention.
• Collaborate with department leaders to address deficiencies and implement corrective actions promptly.
• Partner with clinical and administrative leaders to align departmental initiatives with organizational priorities.
• Communicate effectively with senior leadership, providing regular updates on performance, risk status, and infection prevention efforts.
• Collaboration with state and local public health offices.
• Perform other duties as assigned.

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Life insurance
• 401k with employer matching

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree