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.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Performs scheduled, random and focused medication management audits focused on controlled substances and other medications as directed. (60%)
• Collaborates with Clinical Leaders to resolve identified variances. (15%)
• Updates automation systems and data analytics tools to optimize proactive diversion search functions. (10%)
• Compiles data into a dashboard to demonstrate overall program compliance. (10%)
• Presents data and participates in monthly ministry program calls. (5%)
• 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.

• 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.

• 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.

• BA/BS in Accounting, Business, Information Systems, or a related field preferred.
• 2 years of experience, including co-op assignments, in internal audit, public accounting, or commensurate healthcare experience preferred.
• Medical experience preferred.
• LVN/ CPhT preferred