Quality, Risk, Infection Control Manager
Company: Coalinga Regional Medical Center
Location: Coalinga
Posted on: February 11, 2026
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Job Description:
Job Description Job Description Description: DESCRIPTION OF
POSITION This job description is a record of the essential
functions of the listed job. The job description provides the
employee, CEO, Human Resources, applicants, and other agencies with
a clear understanding of the job, where it fits into the
organization, and the skill and work requirements in relation to
other jobs. Jobs are always changing to some degree and the
existence of the approved job description is not intended to limit
normal change and growth. The facility will make reasonable
accommodations to otherwise qualified individuals who are capable
of performing the essential functions of the job with or without
reasonable accommodation. POSITION SUMMARY This position is
responsible for establishing and maintaining a quality assurance
system that promotes customer satisfaction, risk assessment, and
improvement performance of the facility and infection prevention
and control. Leads and directs performance/process improvement
activities that provide more efficient and streamlined workflow in
a hospital environment. Presents results of improvement efforts and
ongoing performance measures of clinical processes within the
hospital to the management team. They also have participatory
responsibility for regulatory body surveys, such as DNV, State
Licensing Review, and CMS Validation surveys. Maintains
responsibility for all quality and performance improvement
activities conducted throughout the hospital. They are responsible
for the reporting to various mandated reporting to agencies such as
CMS, CDPH, CDC, NHSN, etc. DUTIES AND RESPONSIBILITIES Develop,
implement, manage and integrate strategic plans for overall health
care improvement, which includes Quality Indicators, Compliance
reporting, Patient Satisfaction survey, and Performance Improvement
processes. Serve as the primary quality control resource for
problem identification, resolution, loss reporting and continuous
improvement. Support concurrent engineering efforts by
participating in design development projects representing quality
assurance and the customer. Establish and implement metrics
(process capability, control charts, measurement quality) for
monitoring system effectiveness and to enable managers to make
sound product quality decisions. Perform root-cause analysis and
other problem solving activities to identify effective corrective
actions and process improvements. Educate and train employees as to
their impact in the quality management system when needed.
Establish collection and analysis systems of statistical data to
predict trends that will affect improvement of product quality.
Infection Prevention & Control Implement infection control
measures, including isolation precautions and sterilization
techniques in accordance with current rules, regulations, and
guidelines that govern such requirements in nursing care facilities
Conduct surveillance of infection rates and report findings to the
infection control committee. Educate staff on infection prevention
protocols, including hand hygiene, personal protective equipment
(PPE) use, and safe handling of biohazard materials. Develop and
implement infection prevention policies and procedures in
collaboration with the DON. Tasks involve light contact with moist
body substances, non-intact skin or mucous membranes. Department
procedures define and require use of minimum protective measures to
perform the task. Ensure that the facility is in compliance with
current CDC, OSHA, and local regulations concerning infection
control or standard/ universal precautions. Includes other duties
assigned by Director of Nursing or CAO. Collaboration and Education
Serve as a resource for infection prevention best practices to
nursing and clinical staff. Participate in interdisciplinary rounds
and provide input on infection control. Educate/In-service of
nursing staff, new hires, and yearly to ensure competency nursing
personnel Assist all departments in evaluating and classifying
routine and job-related functions to ensure that tasks involving
exposure to blood/body fluids are properly identifies. Working
knowledge of OSHA Blood borne Pathogen Standards, OSHA
Tuberculosis, Title 22, State and Federal laws related to
communicable disease, and DNV Standards. Documentation and
Reporting Maintain accurate documentation of infection prevention
activities, and patient progress in electronic medical records
(EMR). Prepare infection surveillance reports and data analysis for
infection control meetings per facility protocol and accrediting
body standards. Prepare infection surveillance reports and data
analysis for monthly reporting to National Healthcare Safety
Network (NHSN) Prepare infection surveillance reports and data
analysis of ‘reportable’ cases for County Public Health. Maintain
culture and sensitivity logs for Hospital Acquire Infection
tracking for Emergency Department, Acute Care, and Medical
Specialty Centers. Prepare infection surveillance reports and data
analysis for Internal auditing and Quality improvement projects.
Requirements: POSITION QUALIFICATIONS Certified Professional in
Healthcare Quality is preferred. The knowledge and abilities
required to perform this function are typically acquired through
training and experience equivalent to four (4) years of experience
in an acute care hospital setting. Nursing management experience is
desirable but not required. Valid LVN license in California, RN
Preferred Strong organizational, time management, and communication
skills. Familiarity with infection prevention protocols. 2 years of
clinical experience in infection prevention preferred. Previous
experience in an acute care, long-term care, or similar healthcare
setting desirable. Must obtain certification in Infection
Prevention and Control (IPC) within 6 months of hire and maintain
active certification throughout employment to meet industry
standards. Special/Skills and/or Equipment Used: Demonstrated
ability to plan, set, and accomplishes multiple objectives.
Attention to detail, exhibit self-direction, high degree of
independence, judgment and discretion, teaching ability, effective
oral and written communication skills, demonstrated ability to work
effectively with others as a team member. Requires the ability to
work with highly confidential and sensitive information. Must have
analytical and problem solving skills as well as the ability to
coordinate and communicate effectively with diverse others
including, colleagues, managers, medical staff and be able to teach
and develop others. Must be able to prioritize, make decisions and
set clear expectations for others. Must possess excellent
negotiation skills. Must be computer knowledgeable. Access to
Protected Health Information: This position may have access to
protected health information on a given project. The protected
health information, this position may access demographic
information, date of service information, Insurance/billing
information and/or medical record summary information. This
position requires patient health information in order to perform
the functions outlined as part of this position description.
Keywords: Coalinga Regional Medical Center, Fresno , Quality, Risk, Infection Control Manager, Healthcare , Coalinga, California