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Job Description

Responsible for all regulatory and compliance related activities, coordination, record keeping and presentation for all of the facilities within the Mount Sinai Health System pharmacies. Works with the Compliance/Regulatory department to plan and coordinate activities of the pharmacy department that enable regulatory compliance to be achieved and maintained. Identifies and supports hospital departments and operational leadership in formulating, integrating and implementing medication related policies, procedures and programs that address regulatory compliance.

Qualifications

Minimum Qualifications:

Bachelor of Pharmacy Degree. Current New York State Pharmacist License.

Five (5) years of hospital experience, including experience in process/workflow design and related policy procedure.

Preferred:

Advanced Degree (M.S., MHA, PharmD)

PGY2 HSPAL

ASHP Pharmacy Accreditation and Regulatory Compliance Certificate

Competencies:

• Demonstrates knowledge of the organizations Service Standards and incorporates them into the performance of duties.

• Demonstrates knowledge of the Regulatory and Accreditation Requirements, Rules and Codes and incorporates them into the performance of duties.

Non-Bargaining Unit, 600 - HSO Pharmacy - MSH, Mount Sinai Hospital

Responsibilities

• Reviews and disseminates information pertaining to Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), New York State Department of Health (NYSDOH), New York State Office of Mental Health (NYSOMH), and other compliance activities.

• Identifies the needs for, as well as designs, implements, and monitors process/activities to assure pharmacy compliance with standards and facilitates ongoing survey readiness.

• Pharmacy/Nursing point person for workflow and process updates as it relates to diversion.

• Oversees the Drug Diversion Prevention Program including the implementation and maintenance of the Drug Diversion Prevention software

• Is accountable for all aspects of drug diversion education, prevention, monitoring, investigation, and reporting in an effort to reduce harm to patients.

• Facilitates prioritization of improvement activities related to controlled substance management and shares knowledge as a subject matter expert.

• Oversees the compliance as it relates to controlled substance record keeping.

• Identifies areas for reporting of required pharmacy information to regulatory agencies.

• Communicates departmental progress, areas on concern and problems.

• Collaborates with Administrative and Clinical leadership in implementing the Regulatory Readiness Plan. Represents the regulatory perspective through participation on pertinent hospital committees.

• Develops and maintains required resource and in-services materials for staff.

• Pursues a planned program of professional development through continuing education, seminars, webinars, and applicable journal newsletter and participates in scholarly/professional activities.

• Provides a forum for interdisciplinary dialogue for direct care providers (i.e., pharmacy/nursing committee).

• Serves as a member of the pharmacy departments’ leadership team.

• Supports an environment dedicated to the safety of our patients and staff, and facilitate safety-improvement changes in the medication-use physical environment (USP 797/800).

• Participates in the development and assessment of a pharmacy quality improvement program.

• Designs and manages a QA (Quality Assurance) program for order verification and comprehensive pharmaceutical care.

• Oversees all aspects of medication-related policies and procedures i.e., policies and procedures are disseminated, enforced, effective, applicable, up-to-date, and meet regulatory standard.

• Precepts pharmacy students and residents as assigned.

• Designs and manages pharmacy’s compliance audit program.

Duties and Task:

• Survey participation for accreditation, reaccreditation, validation, allegation, unannounced regulatory surveys. Provides consultation for pre-survey rounds, survey preparation planning, and follow-up for corrective action implementation.

• Orients, educates and works with internal and external staff in performing survey preparation activities including but not limited to Mock Tracers, Secondary Tracers, Safety and Weekly Walk rounds, as well as the Periodic Performance Review (FSA) tool.

• Plans, organizes, and coordinates with other departments receipt of information/documentation required to demonstrate compliance with standards and regulations.

• Coordinates Pharmacy Regulatory and Compliance initiatives for all pharmacies in the enterprise and ensures all pharmacies are within compliance for Joint Commission.

• Implements appropriate changes to policies and procedures based on identified interdisciplinary trends.

• Keeps record of all competencies for all Mount Sinai Health System pharmacy sites. Designs and implements CQI (Continuous Quality Improvement) initiatives.

About Us

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

“About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.”

EOE Minorities/Women/Disabled/Veterans

Compensation Statement

Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $127044 - $190565 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.