The Compliance Nurse plays a critical role in ensuring that AHS facilities operate in accordance with federal, state, and local regulations, as well as internal policies and procedures. This position involves monitoring clinical practices, conducting audits, reviewing documentation, and educating staff to maintain high standards of patient care and regulatory compliance.

The Compliance Nurse works closely with clinical teams, quality improvement departments, and administrative leaders to identify areas of risk and implement corrective actions. They help ensure adherence to regulations such as HIPAA, CMS guidelines, Joint Commission standards, and other relevant laws governing healthcare delivery.

The Infection Preventionist is responsible for developing, implementing, and monitoring AHS’s infection prevention and control programs. This role ensures compliance with local, state, and federal regulations, including CDC, OSHA, and Joint Commission standards, to safeguard patients, staff, and visitors from healthcare-associated infections (HAIs).

Working closely with clinical and administrative teams, the Infection Preventionist leads efforts to reduce infection risks through surveillance, staff education, policy development, and outbreak response. This position plays a key role in promoting a culture of safety and continuous quality improvement.

Primary Job Functions:

Compliance:

• Conduct regular audits and reviews of clinical documentation and processes (e.g. record reviews, chart audits, peer reviews, compliance rounds and facility walkthroughs.)
• Monitor compliance with healthcare regulations and standards to include but not limited to those of the Alabama Department of Public Health (ADPH), Alabama Department of Mental Health (ADMH), The Joint Commission, the Administration for a Healthy America (AHA; formerly HRSA, SAMHSA and NIOSH), Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).
• Educate and train staff on compliance protocols and best practices.
• Assist in developing and updating policies and procedures.
• Investigate compliance-related incidents and support corrective action planning.
• Prepare reports for leadership and regulatory agencies as required.
• Collaborate with leadership and interdisciplinary teams to promote quality improvement and patient safety.
• Ensure compliance with CLIA regulations by overseeing laboratory testing processes, maintaining accurate documentation, conducting quality control reviews, and ensuring proper staff training and competency. Monitor laboratory practices to ensure adherence to federal standards and assist with inspections, audits, and corrective actions as needed.

Infection Control:

• Develop and maintain infection prevention and control policies and procedures.
• Conduct surveillance of healthcare-associated infections and report findings to appropriate stakeholders.
• Investigate infection outbreaks and coordinate response efforts.
• Monitor compliance with infection prevention protocols and conduct audits and risk assessments.
• Develop an annual Infection Control Plan based on completed risk assessments, incorporating measurable goals to address identified infection trends and outlining recommended corrective actions.
• Chair Infection Control Committee. Collaborate with interdisciplinary committee(s) on performance improvement initiatives to include but not limited to antibiotic stewardship, illness reporting, and hand hygiene.
• Coordinate, analyze, and report surveillance data quarterly to the Infection Control Committee.
• Prepare and submit reports to regulatory bodies as required.
• Educate staff on infection control practices, including hand hygiene, PPE usage, and sterilization techniques. Provide training during new employee orientation and as needed to reinforce best practices or address identified gaps.
• Provide consultation and administer first aid for employee and patient exposure incidents, including needlestick injuries, bloodborne pathogen exposure, and other contact with potentially infectious materials. Ensure timely reporting, initiate appropriate follow-up procedures, and coordinate post-exposure evaluations and treatment in accordance with regulatory guidelines and AHS protocol.
• Coordinate and conduct employee health screenings and vaccinations programs for communicable diseases, including tuberculosis (TB), Hepatitis B, COVID-19, and influenza. Administer medications and vaccines as authorized by standing orders or as directed by a licensed prescriber.
• Maintain employee health records including screening, testing and vaccination administration in electronic format.
• Coordinate, promote, and assess the seasonal influenza vaccination program.
• Maintain adequate supplies for the employee health program.
• Establish and maintain professional communication with the state and local health departments.

   Administrative and Other Related Duties as Assigned:

• Maintain current nursing license and specialized infection control training as required.
• Maintain a current working knowledge of performance improvement, infection prevention and control, occupational health, and safety practices, and actively participate in related initiatives and activities as appropriate.
• Works in a dependable, cooperative, and positive manner with all AltaPointe staff members
• Treats patients and employees with dignity and respect
• Completes assigned tasks in a timely manner
• Perform other duties as assigned to support the overall goals and operations of the department and organization.

Current RN license to practice in the state of Alabama. BSN or MSN preferred. Certification in Infection Control (CIC) or willingness to obtain, preferred.  Minimum of five years of experience in nursing within a medical setting.   Current Basic Life Support (BLS) certification.   Strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.).

Knowledge of infection prevention and control principles; occupational health; education presentations; and items outlined below, required to be attained within six (6) months of employment:

• Knowledge of MindSet Behavioral Intervention Principles
• Specialized training (if not CIC) in infection control and prevention