Infection Control Director and Employee Health

Department: Infection Prevention / Employee Health

Reports To: Chief Clinical Officer (CCO)

Position Type: Director

Job Summary

The Infection Control Director & Employee Health is responsible for the development, coordination, implementation, and evaluation of the hospital-wide Infection Prevention and Control program in compliance with CMS Conditions of Participation, CDC guidance, state regulations, and accreditation standards applicable to Critical Access Hospitals. This position also coordinates designated Employee Health functions, including employee immunizations, exposure records, and related employee health initiatives. The role collaborates with hospital leadership, Human Resources, medical staff, Pharmacy, department directors, and frontline staff to support infection prevention, employee safety, regulatory compliance, and survey readiness.

Essential Functions

• Organize and coordinate Infection Prevention and Control Committee meetings.
• Collaborate with department directors regarding infection prevention and employee health staff education and training needs.
• Maintain active involvement in CCO-directed clinical committees.
• Perform other duties as assigned or requested.

Infection Prevention and Control

• Oversee and maintain the hospital-wide Infection Prevention and Control program in accordance with CMS and CDC standards.
• Conduct infection surveillance, data collection, analysis, trending, and reporting.
• Develop, review, and update infection prevention policies, procedures, and the Infection Control Plan.
• Evaluate the effectiveness of the Infection Control Plan annually.
• Coordinate outbreak response and required public health reporting.
• Provide infection prevention consultation and guidance to staff, physicians, and hospital leaders.
• Maintain infection prevention documentation to support regulatory and accreditation survey readiness.
• Coordinate infection prevention education based on identified risks, surveillance findings, policy changes, and staff needs.
• Oversee the Antibiotic Stewardship Program in collaboration with the Pharmacy Director and other appropriate clinical leaders.

Employee Health Coordination

• Collaborate with Human Resources and leadership in coordinating employee immunization and occupational exposure records.
• Assist with coordination of employee exposure evaluation, documentation, and follow-up processes in accordance with hospital policy.
• Assist with coordination and tracking of employee health screenings/testing/immunizations, and related follow-up activities.
• Coordinate employee health initiatives and programs related to infection prevention and occupational health.
• Maintain confidentiality of employee health information and records.
• Identify employee health trends or infection-related risks and communicate findings to appropriate hospital leadership.

Professional Requirements

• Minimum of three (3) years of healthcare experience required.
• Registered Nurse (RN) preferred but not required.
• Non-RN candidates must demonstrate appropriate education, training, and experience for assigned responsibilities.
• Current Basic Life Support (BLS) certification.
• Infection prevention training and ongoing education appropriate to the role and assigned responsibilities.

Knowledge, Skills, and Abilities

• Knowledge of infection prevention principles, surveillance practices, and employee exposure processes.
• Ability to compile, categorize, analyze, verify, and report information and data.
• Strong organizational and interpersonal skills.
• Ability to work independently and manage multiple simultaneous responsibilities.
• Ability to maintain confidentiality of medical, employee, financial, and legal information.
• Ability to complete work assignments accurately and on time.
• Excellent verbal and written communication skills.
• Ability to handle difficult situations involving employees, patients, physicians, or others professionally.