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Job Description

The Quality Assurance & Infection Prevention Manager is a key member of the clinical leadership team responsible for directing the facility’s quality assurance/performance improvement (QAPI) and infection prevention and control (IPC) programs. This role plays a vital part in achieving optimal resident outcomes by analyzing data, driving compliance, coaching staff, and leading strategic efforts to improve the facility’s CMS Quality Measure (QM) star rating. Expertise in MDS (Minimum Data Set) processes and their impact on quality metrics is essential.

Position Duties

Quality Assurance & Performance Improvement (QAPI):

- Contribute to the QAPI program in accordance with CMS and state regulations, in improving the CMS Five-Star Quality measures

- Analyze quality metrics, clinical outcomes, and care trends to identify opportunities for improvement.

- Collaborate with the interdisciplinary team to develop and implement performance improvement projects (PIPs).

- Use data from MDS assessments to guide strategies aimed at improving CMS Five-Star Quality Measures.

- Work with the MDS Coordinator to ensure accuracy and timeliness of MDS submissions.

- Lead efforts to improve the facility’s QM star rating through focused interventions and monitoring.

- Prepare and present quality reports for leadership and regulatory review and

- Prepare for state regulator survey and participate in the process.

- Document monthly QAPI committee meetings in the Five-Star Quality Measures.

-Oversees and manages the MDS team.

Infection Prevention & Control:

- Serve as the facility’s designated Infection Preventionist (IP) as required by CMS F880.

- Develop and manage a comprehensive infection prevention and control program, including surveillance and outbreak response.

- Monitor antibiotic use and healthcare-associated infections (HAIs).

- Educate staff on infection prevention policies and practices, including PPE use, hand hygiene, and isolation precautions.

- Stay current on guidance from NHSN, CDC, CMS, OSHA, and state/local public health authorities.

MDS & Quality Measures:

- Partner with the MDS Coordinator to ensure accurate coding and supportive documentation for quality measures.

- Interpret MDS-derived data to understand trends, identify outliers, and drive improvement plans.

- Provide staff education on documentation practices that support accurate MDS assessments.

- Monitor specific quality indicators such as falls, pressure ulcers, ADL decline, weight loss, antipsychotic use, and readmissions.

Staff Education & Compliance:

- Educate staff on QAPI principles, infection prevention, and quality documentation.

- Coach and mentor staff to ensure compliance with clinical standards and regulatory expectations.

- Prepare the facility for state and federal surveys through proactive monitoring and audit readiness.

- Promote a culture of safety, accountability, and continuous improvement.

Requirements

Education and Experience

- Registered Nurse (RN), licensed in the state of Montana

- Bachelor of Science in Nursing (BSN) preferred.

- Certification in Infection Control (CIC) or willingness to obtain within 12–18 months.

- Training in QAPI and/or Quality Improvement methodologies preferred.

- RAC-CT certification (Resident Assessment Coordinator – Certified) preferred or willingness to obtain.

- Minimum of 3 years of clinical nursing experience in long-term care or related healthcare setting.

- Minimum of 2 years of experience in quality assurance, infection control, or MDS coordination.

- Proven track record in improving or maintaining CMS Quality Measure star ratings.