[Hiring] Director of Nursing Policy, Standards and Accreditation @LUX Infusion

Role Description

The Director of Nursing Policy, Standards, and Accreditation is responsible for ensuring all company ambulatory infusion centers (AICs), ambulatory infusion suites (AIS’s) and home infusion nursing maintain continuous compliance with all applicable nursing accreditation and regulatory standards. This role oversees audit readiness at all times, coordinates accreditation activities, and collaborates closely with nursing operations leadership to ensure standards are integrated into daily operations. The Director is responsible for Nursing standards and primary responsibilities include:

• Participating in the standards development/revision process
• Conducting regular site visits
• Providing educational instruction through standards workshops
• Managing nursing policy and procedure
• Serving as the company’s subject matter expert in nursing accreditation compliance

This position supports accreditation services staff in completing scheduled work on time in accordance with LUX Infusion policies and procedures. The Director of Nursing Policy, Standards, and Accreditation is an integral contributor in providing strategic oversight for all accreditation, policy, and quality services, including:

• Monitoring, evaluating, suggesting, and implementing needed changes
• Continuous quality improvement
• Providing clinical guidance to management and operational leadership
• Oversight of the Performance Improvement and Quality Management Committee Program

Qualifications

• Current, unrestricted Registered Nurse (RN) license (multi-state/compact preferred)
• Bachelor of Science in Nursing (BSN) required; MSN or advanced degree preferred
• A minimum of five (5) years of experience in a healthcare organization with quality, compliance, and accreditation leadership required
• Minimum of three (3) years of administrative experience developing and writing accredited applications and policies required
• Demonstrated experience managing multi-site accreditation efforts and maintaining continuous audit readiness
• Deep knowledge of and experience with ACHC and/or URAC standards
• Strong knowledge of state and federal nursing regulations
• Excellent verbal, written, and presentation skills
• Operational or clinical experience with ambulatory infusion centers (AIC’s), ambulatory infusion suites (AIS’s), Home Health Care services
• Experience with clinical quality programs and performance improvement initiatives
• Experience providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction
• Requires problem solving, judgment and/or research to carry out complex procedures and/or recommend courses of action where no precedents or policies exist
• Intermediate level skill in Microsoft Office (including Word, Excel, PowerPoint, etc.)

Requirements

• Strongly preferred experience with NICA and ACHC accreditation
• Experience with other accrediting bodies such as Joint Commission, NABP, etc. preferred
• Experience at director or manager level in the infusion and/or specialty pharmacy, ambulatory infusion center or suite, or home care industry preferred
• Masters or other advanced degree preferred
• Experience and a strong knowledge base in infusion therapies i.e. chronic, specialty, and acute therapies

Benefits

• Competitive salary range: $145,000 — $160,000 USD

Essential Functions and Responsibilities

• Serve as the primary accreditation lead for all applicable nursing accreditation programs
• Develop and deliver workshops for facilities, programs, and site visitors
• Accreditation services staff to update documents (applications, worksheets, accreditation manual, policy manual)
• Review and implementation of Accreditation Standards
• Serve as the primary point of contact for assigned applications
• Communicate with applicants utilizing positive customer relation skills
• Analyze applicants’ submitted documentation utilizing accreditation scoring methodology to determine eligibility for proceeding with the accreditation processes
• Discuss findings with the applicants and LUX Infusion in an educational manner
• Draft and submit written executive summaries and present findings to the Accreditation Committees and LUX Infusion
• Conduct required follow-up activities of applicants such as onsite reviews
• Report any delay in the timely processing of applications to the Compliance and Privacy Officer as well as Senior Vice President of Nursing
• Assist in providing technical support and advice to accrediting bodies and Standards Committees
• Participate in Nursing standards development/revision process for the specific program
• Partner with Nursing and Ambulatory Infusion Center/Suites leaders to embed accreditation requirements into standard workflows
• Lead the development, maintenance, and approval process for all nursing-related policies and procedures
• Manage accreditation and policy/procedure integration during new mergers or acquisitions
• Plan, prepare, and lead internal audits and mock surveys; develop and oversee corrective action plans
• Conduct regular on-site visits to locations to verify compliance and provide operational support
• Act as the primary liaison with accrediting organizations, responding to inquiries, preparing required documentation, and coordinating site surveys
• Oversee Performance Improvement/Quality Management initiatives related to accreditation compliance
• Provide regular reports to the Compliance & Privacy Officer on accreditation status, identified risks, and improvement initiatives

Supervisory Responsibility

This role oversees AIC and Nursing Accreditation Specialist(s) and Quality Specialist(s).

Knowledge, Skills and Abilities Requirements

• Strong leadership presence with the ability to inspire confidence, foster trust, and serve as an approachable resource to staff at all levels
• Demonstrated consultative style, with the ability to guide cross-functional teams, influence stakeholders, and drive alignment on complex issues
• Exceptional interpersonal and communication skills, including the ability to present ideas clearly, listen actively, and adapt style to diverse audiences
• Proven ability to build and maintain collaborative partnerships, both internally and externally, to achieve organizational goals
• Skilled at managing through ambiguity, balancing competing priorities, and facilitating consensus in fast-paced environments
• High emotional intelligence, with a focus on empathy, integrity, and the ability to cultivate a positive organizational culture
• Knowledge of nursing, drug, and related laws of the state along with prescription monitoring programs
• Knowledge of the basic sciences underlying nursing, such as anatomy, biology, and physics
• Knowledge of accreditation requirements and process, ability to write and implement policies and procedures
• Ability to apply safety and efficiency in the prescribing, dispensing, administering, and use of drugs and related articles for the prevention of illness and the maintenance and management of health
• Ability to analyze and understand Physicians' or other recognized medical personnel's oral or written orders involving standard symbols and terminology
• Ability to maintain accurate records and prepare reports and correspondence related to the work
• Ability to oversee nursing operations of multiple branch locations
• Advanced reasoning, analysis, language ability (reading, writing, and speaking)
• Ability to handle conflict and to exercise sound judgment
• Ability to think and act strategically and proactively
• Ability to maintain favorable public relations
• Ability to organize and coordinate the work of others
• Ability to set priorities and assign work to other professionals
• Excellent analytical skill

Communication Skills

• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings
• Written Communication - Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information

Computer Skills

• Become and remain proficient in all programs necessary for execution

Physical Demands

The physical demands described here represent those required for an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions. If you require a reasonable accommodation during the application or interview process, please contact the LUX Infusion Talent Team at [email protected] or 954.385.7322 x 1425.

• Occasionally required to stand, walk, or sit
• Use hands to finger, handle, or feel objects, tools, or controls
• Reach with hands and arms; climb stairs; balance; stoop, kneel, crouch, or crawl; and talk or hear
• Occasionally lift and/or move up to 25 pounds
• Specific vision abilities required include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus

Other Requirements

• Participate annually in required legal and ethical compliance training
• Consistently act in compliance with LUX Infusion’s legal, ethical, and compliance policies
• Adhere to all standards and procedures outlined in the LUX Infusion Compliance Manual
• Refrain from any behavior that could be considered unethical or unlawful

Expectations for All Employees

All LUX Infusion team members are expected to support the organization’s mission, vision, and values by demonstrating integrity, dedication, compassion, and enthusiasm. This includes placing patients first, working collaboratively with a “stacked-hands” mindset, and maintaining a consistent focus on quality, accountability, and continuous improvement.

General Information

The statements above are intended to describe the general nature and level of work performed by individuals in this role. They are not intended to be an exhaustive list of all responsibilities, duties, or skills required. This role operates in a fast-paced environment and requires the ability to prioritize competing demands, manage multiple tasks effectively, and seek guidance when appropriate.

Employees in this position may be required to assist directly - or coordinate appropriate assistance - to ensure access to LUX Infusion’s services for individuals with disabilities, including patients, visitors, employees, or others.

LUX Infusion is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law.