MHN Pharmacy Compliance Coordinator

Responsibilities

• Coordinate pharmacy compliance initiatives across Marshall Health Network to ensure compliance with federal and state regulations, accreditation standards, and organizational policies.
• Serve as a system resource for controlled substance oversight and diversion prevention.
• Maintain automated dispensing cabinet (ADC) controlled substance discrepancies and facilitate timely resolution.
• Analyze controlled substance utilization data to identify trends, unusual activity, and potential diversion concerns.
• Conduct compliance audits of pharmacy operations, medication storage, documentation, and controlled substance processes.
• Support diversion investigations in collaboration with pharmacy leadership, nursing, Human Resources, Security, Compliance, and other stakeholders.
• Monitor compliance with DEA requirements, Board of Pharmacy regulations, and USP Chapters , , and .
• Develop and maintain compliance dashboards, audit tools, reports, and key performance indicators.
• Track corrective action plans and monitor progress toward resolution.
• Support compliance activities for Alternative Distribution Models (ADMs) and decentralized pharmacy operations.
• Collaborate with operational leaders to standardize workflows and implement process improvements.
• Provide education and training on pharmacy regulatory requirements, controlled substance accountability, documentation standards, and compliance best practices.
• Participate in quality improvement initiatives, pharmacy committees, and organizational projects that enhance regulatory compliance and patient safety.

Qualifications

• Bachelor’s degree in Pharmacy, Healthcare Administration, or related field.
• Minimum 5 years of experience in a hospital pharmacy setting, including experience in compliance and quality assurance.
• Knowledge of federal and state pharmacy regulations, accreditation standards, and organizational policies.
• Experience with automated dispensing cabinets (ADCs) and controlled substances.
• Strong analytical skills and ability to interpret complex data.
• Excellent communication and interpersonal skills, with the ability to collaborate effectively with various departments within the organization.
• Proficiency in Microsoft Office Suite, including Excel and PowerPoint.