Sepsis Program Manager (Registered Nurse)

Overview

The Sepsis Program Manager is responsible for leading the planning, coordination, implementation, and evaluation of Memorial Health’s Sepsis Program across all acute care and critical access hospitals. This role provides clinical and operational expertise to drive early identification, evidence-based treatment, and ongoing performance improvement for patients with sepsis and septic shock. Working collaboratively with physicians, nursing leadership, quality, infection prevention, emergency departments, and critical care teams, the manager ensures alignment with national standards (e.g., CMS SEP-1), current evidence, and system strategic priorities. The manager serves as a system resource for data analysis, best practice implementation, education, and regulatory compliance.

Responsibilities

1. Program Leadership & Alignment

• Serve as the system-wide clinical and operational leader for Memorial Health’s Sepsis Program.
• Lead the design, implementation, and evaluation of the sepsis program strategy across all hospitals and ED settings.
• Ensure alignment of sepsis protocols, policies, and workflows with regulatory standards and national best practices.
• Lead or co-chair Sepsis Committee, ensuring cross-disciplinary participation and consistent follow-through on improvement initiatives.
• Act as a liaison to hospital-based Sepsis Nurse Navigators and operational leaders to support real-time bundle compliance and escalation pathways.
• Works under minimal supervision and exercises independent judgment in aligning program priorities with organizational goals.

1. Performance Improvement & Data Oversight

• Lead system monitoring and performance tracking for SEP-1 and other sepsis quality measures.
• Collaborate with quality analytics and infection prevention teams to collect, analyze, and interpret sepsis performance data.
• Identify trends, gaps, and opportunities for improvement, and partner with hospital teams to implement corrective action plans.
• Develop and distribute regular system sepsis dashboards and reports for hospital and system leadership.

1. Education & Evidence Integration

• Monitor current research and national recommendations related to sepsis care; translate evidence into practice through protocols, toolkits, and education.
• Develop and deliver education to physicians, nurses, and ancillary staff regarding early identification, timely treatment, and best practices for sepsis care.
• Develop patient and family education resources related to sepsis.

1. Regulatory & Compliance

• Ensure system sepsis program compliance with CMS, Joint Commission, and other accrediting/regulatory agencies.
• Collaborate with legal, compliance, and quality teams on regulatory updates.

1. Collaboration & Consultation

• Serve as a subject matter expert and consultant to clinical teams across the system.
• Foster collaboration between ED, inpatient, critical care, lab, pharmacy, and infection prevention teams to strengthen sepsis workflows.

Qualifications

Education:

·        Master’s degree in nursing, Healthcare Administration, Public Health, Business or related field
Licensure/Certification/Registry:

·         Registered Nurse (RN) license in state of Illinois required

·         National certification in critical care, emergency nursing, or quality improvement strongly preferred
Experience:

·         Minimum 5 years of relevant clinical experience in emergency, critical care, or similar acute care setting.

·         Experience with performance improvement initiatives, regulatory reporting, and interdisciplinary collaboration required.

·         Program coordination or leadership experience preferred

·         Data collection experience preferred
Other Knowledge/Skills/Abilities:

·         Strong ability to communicate and influence across disciplines and hospital sites. Data literacy and ability to interpret clinical and performance data.

·         Knowledge of CMS Sep-1 Core Measure and evidence-based sepsis care guidelines.

·         Facilitation, project management, and change leadership skills.