Responsible for aggregating controlled substance accountability information for internal/external DEA reporting requirements. Ensures that data is complete and produces regular (daily, monthly, etc.) and ad hoc reports as directed. Extracts data from multiple data sources, as needed, to inform, analyze and report on regular and ad hoc inquiries.
Responsible for obtaining data from multiple systems needed for the surveillance of the controlled substance distribution and use processes. Producing unit based reports from multiple data sources for Nurse Managers that identify diversion potential. Ensures that data is complete and produces regular (daily, monthly, etc.) and ad hoc reports as directed.
60% Performs scheduled, random and focused medication management audits focused on controlled substances and other medications as directed.
15% Collaborates with Clinical Leaders to resolve identified variances.
10% Updates automation systems and data analytics tools to optimize proactive diversion search functions.
10% Compiles data into a dashboard to demonstrate overall program compliance.
5% Presents data and participates in monthly ministry program calls.
POSITION SPECIFIC COMPETENCIES (Technical and soft skills unique to job and/or department)
Provide data and analysis to ensure the pharmacy department meets all legal, accreditation, and certification requirements: FDA, Board of Pharmacy, Board of Health, DEA, CMS, USP 797 and JCAHO relating to the prescribing, distribution, dispensing, preparation, storage, administration and disposal of controlled substances
Obtains controlled substance transaction data from all sources
Works collaboratively with Pharmacy, Nursing, Anesthesia, and Ambulatory Care to obtain needed data within the expected timeframe for internal and external reporting.
REPORTS VALIDATED DATA
Responds to requests for controlled substance transaction data, analyses and reports in a timely manner
Plans and executes data queries as needed. Identifies and utilizes key data resources as required to achieve the expected result
Prepares regular and ad hoc reports as required
Validates data thoroughly to ensure accuracy and integrity of all data collection, manipulation and analyses
Prepares reports, graphs, spreadsheets etc. as required for projects or requests
Prepares regular reports of the following transaction types for review by Pharmacy and Nursing leadership: Override, Waste, Discrepancies, Removal of medications outside of their home unit, Inventory
Performs other responsibilities related to reporting of controlled substance transaction related data
Conducts controlled substance surveillance data management activities
Identifying potential for diversion, misuse, theft or significant loss through analysis of Automated Dispensing reports for reporting to Nursing
Generates and reviews monthly Pyxis controlled substance transaction data to identify those that may represent diversion, misuse, thefts, significant loss or trends requiring additional surveillance
Conducts regular audits of Pharmacy controlled substance inventory and distribution transactions and related documentation
Conducts audits of all internal CS records and logs identified deficiencies related to poor or incomplete record keeping and documentation.
Performs audits identified by Pharmacy management as required to meet regulatory or compliance standards; providing data analysis and summary
Serves as a resource to the Internal Auditor during an internal audit
Prepares draft of response to the Internal Audit report
Supports and contributes ongoing measurement and improvement of pharmacy operations.
Identifies potential system vulnerabilities, established medication safety best practices and facilitates medication safety improvement projects. administration, supervision and consolidation of medication safety initiatives
Participates in audits and tracer programs to promote quality of pharmacy services.
Promote and uses lean management principles as the departments primary tool for ensuring a mindful, high reliability culture, elimination of waste, JIT, standard work, quality, promote and comply with standardized procedures/work, identify waste in ownership process and recommend solutions for implementation, correct abnormal condition
Ability to work independently when assigned tasks by Director, Medication Safety and Regulatory Compliance.
Effective interpersonal and communication skills
Possesses excellent organization skills
Meticulous with respect to attention to detail and accuracy
Ability to perform work that is detailed and routine
Possesses excellent verbal and written communication skills
Associate Degree required. BS/BA in Accounting, Business, Information Systems or a related field preferred.
Computer skills, including proficiency with MS Office suite (Word, Excel, Access).
Familiarity with Visio, ACL, Business Objects or other audit software is preferred.
2 years of experience, including co-op assignments, in internal audit, public accounting, or commensurate healthcare experience preferred
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.