Montage Health

Monterey Peninsula health system

Infection Prevention Specialist - RN, Quality Management

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours

Full-timeMonterey, CA, USA$73.91 - $98.85 /hrIn-person

About the Job

Requirements

At least 3 years of recent acute inpatient care experience; ICU, Med-Surg, and emergency department experience are preferred.
A Bachelor of Science in Nursing is required, or the BSN may be in progress with attainment within 12 months of hire.
A current, unencumbered State of California Registered Nurse license is required.
Certification in Infection Control is required or must be obtained within two years of hire.
Proficiency in Microsoft Office and electronic health record systems is required; Epic is preferred.
Familiarity with NHSN reporting, APIC guidelines, and regulatory standards is required.
Working knowledge of Title 22, TJC standards, and CMS Conditions of Participation is preferred.

Responsibilities

Implement and maintain the infection prevention and control program in compliance with CDC, TJC, Title 22, OSHA, APIC, CMS, and state regulations.
Support readiness for regulatory surveys and inspections.
Follow established infection prevention policies and procedures, including aseptic techniques and exposure control.
Lead or participate in mock tracers, audits, and readiness rounds, and maintain evidence of compliance.
Participate in TJC surveys and other regulatory inspections, and coordinate corrective actions and sustainment plans.
Develop, maintain, and provide education on policies, procedures, and standard work related to assigned measures and safety practices.
Provide routine reporting to Administration, Board committees, Medical Staff committees, and quality councils.
Perform routine surveillance for healthcare-associated infections using standardized definitions.
Collect, validate, and enter infection prevention data into NHSN and other required reporting systems.
Monitor trends and assist in preparing reports for committees and leadership.
Partner with Risk Management to review patient safety events, near misses, and grievances; perform targeted chart reviews and case tracers.
Facilitate or contribute to root cause analyses and after-action reviews; develop corrective action plans and monitor their effectiveness and sustainment.
Lead proactive hazard surveillance and failure mode identification, and embed feedback loops such as huddles, visual controls, and standard work audits.
Facilitate Lean Model for Improvement projects using AIM, driver diagrams, and PDSA cycles at unit and service-line levels.
Coach leaders, charge nurses, educators, and physicians on measure definitions, documentation, and bundle reliability tactics.
Design and deliver adult-learning education, including tip sheets, micro-learning, and in-services, based on identified performance gaps.
Lead or co-lead relevant committees and workgroups, such as the Infection Prevention Work Group and unit-based councils.
Prepare agendas, minutes, dashboards, and storyboards; track actions to closure and communicate progress.
Maintain relationships with Nursing, Medical Staff, Case Management, Infection Prevention, Pharmacy, Laboratory, Radiology, and IT/Analytics.
Provide supported groups with reliable data, coaching, and process-improvement support.

Desired Qualifications

Prior experience in infection prevention is strongly preferred.
A master's degree in Nursing, Healthcare Administration, Public Health, or a related field is preferred.
Experience in ICU, Med-Surg, or emergency department settings is preferred.
Epic experience is preferred.
Working knowledge of Title 22, TJC standards, and CMS Conditions of Participation is preferred.

Welcome to Montage Health’s application process!

Job Description:

Under the direction of the Quality Management Director, the Infection Prevention Specialist supports the facility’s infection prevention and control program in compliance with federal, state, and local regulations, as well as organizational policies and standards.

This position focuses on surveillance, data analysis, and implementation of evidence-based practices to prevent healthcare-associated infections (HAIs). The Infection Prevention Specialist collaborates with clinical teams and departments to promote patient safety, provides education on infection prevention practices, and assists with regulatory readiness. Acting as a resource and subject matter expert, the role helps ensure alignment with CHOMP’s strategic goals and quality initiatives.

Essential Responsibilities

Program Operations, Compliance & Readiness

Assist in implementing and maintaining the infection prevention and control program in compliance with CDC, TJC, Title 22, OSHA, APIC, CMS, and state regulations.
Support readiness for regulatory surveys and inspections.
Follow established policies and procedures for infection prevention practices, including aseptic techniques and exposure control
Lead/participate in mock tracers, audits, and readiness rounds; maintain evidence of compliance.
Participate actively during TJC surveys and other regulatory inspections; coordinate corrective actions and sustainment plans.
Develop, maintain, and educate on policies, procedures, and standard work related to assigned measures and safety practices.
Provide routine reporting to Administration, Board committees, Medical Staff committees, and quality councils.

Surveillance & Data Collection

Perform routine surveillance for HAIs using standardized definitions.
Collect, validate, and enter infection prevention data into NHSN and other required reporting systems.
Monitor trends and assist in preparing reports for committees and leadership.

Patient Safety Events, Risk Mitigation & Learning

Partner with Risk Management to review patient safety events, near misses, and grievances; perform targeted chart reviews and case tracers.
Facilitate or contribute to RCAs/After‑Action Reviews; develop corrective action plans (CAPs) and monitor effectiveness and sustainment.
Lead proactive hazard surveillance and failure mode identification; embed feedback loops (huddles, visual controls, standard work audits).

Performance Improvement & Education

Facilitate Lean Model for Improvement projects (AIM, driver diagram, PDSA cycles) at the unit and service line level.
Coach leaders, charge nurses, educators, and physicians on measure definitions, documentation, and bundle reliability tactics.
Design and deliver adult‑learning education (tip sheets, micro‑learning, in‑services) based on identified performance gaps.

Committee & Workgroup Facilitation; Stakeholder Engagement

Lead or co‑lead relevant committees/work groups (e.g., Infection Prevention Work Group, Unit‑based councils, etc.).
Prepare agendas, minutes, dashboards, and storyboards; track actions to closure and communicate progress.
Maintain strong relationships with Nursing, Medical Staff, Case Management, Infection Prevention, Pharmacy, Lab, Radiology, and IT/Analytics.
Provide supported groups with reliable data, coaching, and process improvement support.

Experience

Minimum of 3 years recent acute inpatient care experience (ICU, Med-Surg, ED preferred).

Prior experience in infection prevention strongly preferred.

Proficiency in Microsoft Office and electronic health record systems (Epic preferred).

Familiarity with NHSN reporting, APIC guidelines, and regulatory standards.

Working knowledge of Title 22, TJC standards, CMS Conditions of Participation preferred.

Education

Bachelor’s degree in Nursing (BSN) required or BSN in progress with attainment within 12 months of hire.

Master’s degree in Nursing, Healthcare Administration, Public Health, or related field preferred.

Licensure/Certifications

Current State of California RN license (unencumbered) required.

Certification in Infection Control (CIC) required or obtained within two years of hire.

Equal Opportunity Employer

Salary Range: $153,732 - $205,608

Assigned Work Hours:

Full-time (Exempt)

Position Type:

Regular

Pay Range (based on years of applicable experience):

$73.91

$98.85

About the Company

Montage Health

Monterey Peninsula health system

Montage Health is an independent, nonprofit health system serving residents of Monterey County, California. Its network centers on Community Hospital of the Monterey Peninsula, with services spanning cancer, heart, stroke and maternity care. Beyond the hospital, Montage Medical Group runs primary and specialty care practices, while MoGo Urgent Care handles walk-in needs and Ohana treats children and young people with mental health conditions. The system also runs fitness centers and connects Medicare coverage with coordinated care through Aspire Health. Its parent organization was established in 1981, and the system is headquartered in Monterey, California.

Company size: 1,001-5,000
Company stage: Not listed
Total funding: Not listed
Headquarters: Monterey, CA
Founded: 1981

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