UNIV - Program Manager I - Internal Audit

FLSA: Salaried

Job Summary:

With moderate supervision, the Program Manager conducts the compliance auditing program relating to controlled substances; prepares and completes the related audit work program; determines the accuracy and validity of controlled substance records; determines compliance with policies, regulations, and Federal and State laws; prepares written audit reports in accordance with department policy; destroys contaminated and expired controlled substances as allowed by DHEC; maintains accurate and thorough records of all audits.

This position is responsible for:
*verifying proper controls are in place to prevent or deter diversion of controlled substances from their legal and authorized purpose,
*verifying all required legal documents, reports and records are properly and timely initiated by all disciplines,
*educating employees on proper handling, disposition, and documentation of controlled substances, and verifying proper security measures are adhered to.

Payscale Salary Range: UNIV-Band 7: $49,594.00 - $70,674.00 - $91,755.00 (min - mid - max)

Job Duties:

• 35% - 1.1 Audit controlled substance records to verify proper control and documentation. Job Responsibility: Audit controlled substance records to verify proper control and documentation is maintained. Analyze data for accuracy and compliance with policies, procedures, laws, and regulations. Analyze internal controls over controlled substances Success Criteria: Perform routine audits of MUSC pharmacies, nursing units, clinics, and registered departments. Properly document all audit results in clearly organized work files. Evaluate effectiveness of related policies and procedures. Evaluate risk factors related to controlled substances that are present in daily operation of a University, complex academic medical center and its specialized clinics. - (Essential)
• 15% - 1.2 Timely destruction of contaminated or expired controlled substances. Job Responsibility: Timely destruction of contaminated or expired controlled substances in accordance with Federal and State regulations. Educate research, hospital, and clinic staff on proper procedures for wastage and/or destruction of controlled substances. Success Criteria: Destroy expired controlled substances in each pharmacy area as requested. Destroy contaminated and expired controlled substances within 3 business days of notification by the on-campus nursing units or registered departments. Destroy drugs in outlying clinics/areas within a reasonable time with assurance from the clinic/area that the drugs have been secured. Paperwork is properly completed and maintained. - (Essential)
• 12% - 1.3 Timely preparation of written audit reports. Job Responsibility: Prepare written audit reports for every pharmacy, nursing unit and registered department audited and communicates results to appropriate personnel timely. Success Criteria: Assume responsibility for ensuring that reports are prepared and sent to responsible parties (Nurse Manager, Registrant, CNO, Pharmacy Services) timely. Communicate results to appropriate personnel in person. - (Essential)
• 10% - 1.4 Analyze data for accuracy and compliance. Job Responsibility: Conduct ongoing data analysis of controlled substance activity. Success Criteria: Maintain well-documented work files. Communicate timely with responsible parties regarding results. Refer diversion investigations as warranted. - (Essential)
• 10% - 1.5 Assist DHEC and DEA in conducting inspections. Job Responsibility: Assist DHEC and DEA in conducting inspections and investigations, when necessary. DHEC has increased its oversight of our campus; thus, requiring more assistance from the Controlled Substance Auditor. Success Criteria: Assist DEA or DHEC when requested and as time permits. - (Essential)
• 5% - 1.6 Maintain knowledge of Controlled Substance Registrations (DEA and DHEC) Job Responsibility: Guide and assist Hospital Administration, Pharmacy Services, practitioners and researchers with the application requirements and proper submission for controlled substance registrations. Assure proper security controls are in place to meet the requirements of state and federal regulations. Provide recordkeeping template to researchers to assist with compliance with all state and federal regulations and MUSC policies. Monitor application progress and coordinate resolution of any issues that may arise. Coordinate with the DHEC Bureau of Drug Control and/or DEA for the site inspection and review of the controlled substance regulations and recording requirements. Assist as needed on clinic registrations for MUHA and MUSC Physicians. Success Criteria: Registrations are accurate and received in as timely a manner as possible. Timeliness is somewhat dependent on factors beyond our control (i.e., registrant responsibilities for application completion and security requirements, DHEC and DEA inspection and processing). Paperwork is completed properly, submitted timely, tracked, and maintained appropriately. - (Essential)
• 5% - 1.7 Communicates progress on audits. Job Responsibility: Keeps supervisor(s) aware at all times of progress on audits. Success Criteria: Frequent (daily, if possible) communication with supervisor. Inform supervisor of contact with DEA, DHEC, or other regulatory bodies on a timely basis. - (Essential)
• 5% - 1.8 Conducts training. Other duties as assigned. Job Responsibility: Conduct training on proper handling, disposition, and documentation of controlled substances and use of the ADM. Other duties as assigned. Success Criteria: Participate in new employee orientation, staff meetings, and charge nurse workshops. Conduct in-services on nursing units when requested. Conduct in-services for House Staff, physicians, researchers, etc., as needed or requested. Duties are performed timely in a professional manner. Success factors may vary depending on the assigned duties. - (Essential)
• 3% - 1.9 Maintain contact with individuals responsible for ordering, receiving and distributing controlled substances. Knowledge of the automated dispensing machines (ADM). Awareness of policies and laws. Job Responsibility: Maintain close contact with individuals responsible for ordering, receiving and distributing controlled substances so possible sources of illegal use or distribution of controlled substances may be detected. Understand the capabilities and functions of the ADM used for controlled substances. Maintain full awareness of MUSC, MUHA, and UMA policies and Federal and State laws relating to controlled substances. Success Criteria: Interact with appropriate personnel on a regular basis. Utilize reports generated by the ADM or other software to determine areas or individuals needing attention or review. Able to assist personnel with basic questions that arise with use of the ADM. Keep abreast of changes in Federal and State laws and MUSC, MUHA, and UMA Policies and Procedures as they relate to controlled substances. - (Non-Essential)

Minimum Experience and Training Requirements: A bachelor's degree and three years relevant program experience.

Preferred Experience & Additional Skills: Bachelor's degree in a relevant field and relevant program experience. Ability to interpret and apply controlled substance regulations and MUSC policies and procedures relating to controlled substances and automated dispensing machines (ADMs) is required. Professional, concise and articulate presentation skills. Ability to use computer hardware and software, especially word processing, spreadsheet applications, and pharmacy and medical records systems. Relevant professional certification is preferred. Master's degree in a related field preferred. Must be available on pager 24 hours/day, 7 days/week. Must be able to work flexible hours on occasion.

Physical Requirements: Ability to perform job functions in an upright position. (Frequent) Ability to perform job functions in a seated position. (Frequent) Ability to perform job functions while walking/mobile. (Frequent) Ability to work indoors. (Continuous) Ability to work outdoors in all weather and temperature extremes. (Infrequent) Ability to work in confined/cramped spaces. (Infrequent) Ability to perform job functions from kneeling positions. (Infrequent) Ability to squat and perform job functions. (Infrequent) Ability to perform 'pinching' operations. (Infrequent) Ability to fully use both hands/arms. (Frequent) Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Frequent) Ability to reach in all directions. (Frequent) Possess good finger dexterity. (Continuous) Ability to maintain tactile sensory functions. (Continuous) Ability to lift and carry 15 lbs., unassisted. (Infrequent) Ability to lift objects, up to 15 lbs., from floor level to height of 36 inches, unassisted. (Infrequent) Ability to push/pull objects, up to 15 lbs., unassisted. (Infrequent) Ability to maintain 20/20 vision, corrected. (Continuous) Ability to see and recognize objects close at hand. (Frequent) Ability to see and recognize objects at a distance. (Frequent) Ability to match or discriminate between colors. (Frequent) Ability to determine distance/relationship between objects; depth perception. (Frequent) Good peripheral vision capabilities. (Continuous) Ability to maintain hearing acuity, with correction. (Continuous) Ability to hear and/or understand whispered conversations at a distance of 3 feet. (Frequent) Ability to perform gross motor functions with frequent fine motor movements. (Frequent) Ability to work in dusty areas. (Infrequent)

Departmental Physical Requirements: 40% percent walking/standing, 5% traveling, corrected vision and hearing within normal ranges.

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Opening date: 29 Sep 2020 Eastern Daylight Time
Applications close: