Program Manager, Infection Prevention

Job Description

Centralus Health Mission

Our mission is to deliver high-quality care, empower our teams to succeed and improve the wellbeing of the communities we serve.

Job Summary

The Program Manager of Infection Prevention provides day-to-day leadership and oversight of the Infection Prevention program across Centralus Health hospitals and clinics. This role ensures consistent application of evidence-based practices, accurate surveillance, and compliance with Joint Commission, federal, and state regulations.

Working in close partnership with the System Director of Infection Prevention, the IP Medical Director, and multidisciplinary leaders, the Program Manager of Infection Prevention holds responsibility for validating and providing final sign-off on Hospital-Acquired Conditions (HACs) and reportable events. The Program Manager of Infection Prevention will actively mentor Infection Preventionists, ensuring professional development and skillset advancement. The candidate collaborates with leaders in Nursing, Provider Services, Clinical Data, Education, and Revenue Optimization to align infection prevention goals with enterprise-wide performance, safety, and financial objectives.

Core Job Functions

• Provide direct leadership and supervision to Infection Preventionists, including oversight of daily workflows, performance evaluation, and professional development.*
• Validate surveillance findings and definitions, ensuring final case sign-off in conjunction with the IP Medical Director to maintain accuracy in NHSN and regulatory reporting. Leads exercises of inter-rater reliability among Infection Preventionists to further enhance the integrity of surveillance and reporting.*
• Ensure compliance with Joint Commission standards, CMS Conditions of Participation, and state-level regulatory requirements across all facilities. The candidate will be responsible, consulted and informed on Infection Prevention Leadership across care settings, requiring an understanding of all areas of potential risk across Centralus Health.*
• Partner with the Director of Clinical Data, CMO for Revenue Optimization, and Nursing/Provider leadership to ensure timely and accurate reporting, analysis, and intervention planning.*
• Closely collaborates the Medical Director to direct collaborative improvements with Clinical Documentation Improvement (CDI), Coding, Quality and Revenue Optimization in order to accurately depict care in the Medical Record.*
• Collaborate with Clinical Education to design, deliver, and reinforce training programs that advance infection prevention best practices system-wide.
• Collaborates with Risk Management, Patient Safety and Claims management to ensure escalation of findings that may warrant Peer Review, Incident Reporting, and/or Potentially Compensable Events (PCE).*
• Lead operational huddles, post-exposure reviews, and data-driven interventions, ensuring lessons learned are translated into sustainable practice change utilizing the Institute for Healthcare Improvement's (IHI) Action Hierarchy.*
• Engage with site leaders to analyze variation across entities, using stratified data provided by the Clinical Data team (i.e. - unit, service line, population) to identify opportunities for improvement.
• In partnership with the Director, Infection Prevention and the Sr. Director, Quality Outcomes/ACQO, the Program Manager of Infection Prevention will monitor, track, and report HAC performance and associated financial/brand implications in collaboration with Finance and Marketing/Communications.
• Serve as an escalation point for complex infection prevention issues, facilitating alignment across disciplines and ensuring organizational readiness for surveys and audits.
• Other duties as assigned.

Important Note: (*) indicates an essential function of the job as defined by the Americans with Disabilities Act (ADA). Essential functions are the core duties that are fundamental to the position and must be performed, with or without reasonable accommodation.

Success Factors

Key behaviors, skills, and ways of working that are defined as critical for a candidate to excel and contribute positively to the team and organization. The ideal candidate should be able to:

• Think systemically and not in isolation - aligning infection prevention goals with the larger institutional strategic goals and priorities. You recognize that innovation is not the acquisition of more resources, but rather the intentional design of processes that reduce variation, build resilience, and drive quality outcomes across the system.
• Understand and apply behavior change principles - engaging staff, providers, and visitors in practices that reduce infection risk. You maintain clarity in complex and fast-paced environments, helping others stay focused and aligned even when circumstances are ambiguous or rapidly shifting.
• Demonstrate career-stage mastery of infection prevention - understanding that depending on APIC's competency framework, mastery progresses from foundational technical knowledge to strategic systems thinking, leadership, and innovation. You model this growth while ensuring your team of Infection Preventionists advances their skillsets in a structured and supported manner.
• Adapt continuously to a changing environment - demonstrating agility in response to new epidemiologic threats, regulatory shifts, or operational needs. You seek opportunities for improvement, adopt new approaches, and adjust programs to ensure sustainable infection prevention practices.
• Commit to regulatory fluency and financial stewardship - deepening your knowledge of Joint Commission, CMS Conditions of Participation, NHSN reporting requirements, NYS Regulation (Acute, LTC, & Post-Acute) and the implications of Value-Based Purchasing (VBP) and Hospital-Acquired Conditions (HAC) programs. You proactively identify risks and implement strategies to protect both patient safety and organizational reputation/financial performance.
• Lead and develop high-performing teams - providing coaching, supervision, and evaluation of Infection Preventionists. You create a learning culture where inter-rater reliability, professional development, and accountability are prioritized, ensuring data integrity and consistency of practice across all sites.
• Collaborate across disciplines and functions - partnering with Clinical Data, Coding, CDI, Quality, Risk Management, and Clinical Education to design training, analyze data, and escalate findings. You know when to serve as an escalation point and how to facilitate alignment to resolve complex issues system-wide.
• Translate lessons learned into sustainable change - leading operational huddles, post-exposure reviews, and data-driven interventions. You employ frameworks like the Institute for Healthcare Improvement's (IHI) Action Hierarchy to ensure corrective actions are strong, system-based, and designed for long-term impact.

Education / Experience Qualifications

Required:

• Bachelor's degree in Nursing, Epidemiology, Microbiology, Public Health, or related health sciences.
• Certification in Infection Control (CIC®) required (or must obtain within 1 year of hire).
• 5+ years of progressive infection prevention experience, with at least 2 years in a leadership, supervisory, or system-level role.
• Demonstrated ability to design, facilitate, and sustain improvement teams across hospitals and clinics, ensuring alignment with system priorities and achievement of measurable performance goals.

Preferred:

• Advanced training or coursework in epidemiology, biostatistics, or related fields is beneficial.
• Micro or Credentials in data analytics.
• Demonstrated expertise in surveillance, validation, and reduction of HACs.
• Strong knowledge of NHSN reporting, EHR surveillance tools, and CMS/Joint Commission standards.
• Proven ability to present complex data to diverse audiences, including executives, frontline teams, and external regulators.
• Experience with NHSN, EHR surveillance tools (Epic Bugsy, Theradoc, etc.), and advanced Excel or data visualization platforms (Tableau, Power BI, Qlik).

Physical Requirements

• Must be able to remain at a workstation and move around the workspace as needed to complete job tasks, with or without reasonable accommodation.