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Position Summary

The Pharmacy Accreditation and Quality Assurance position is responsible for supporting the development, implementation, and maintenance of specialty pharmacy accreditation standards, regulatory compliance, and quality improvement initiatives. This role coordinates accreditation readiness activities, maintains policies and procedures, monitors compliance requirements, and conducts quality assurance reviews to ensure adherence to federal, state, and accreditation standards. Collaborates with pharmacy leadership and cross-functional teams to identify compliance gaps, implement corrective actions, and drive continuous process improvement to support operational excellence, patient safety, and ongoing accreditation compliance.

Key Performance Areas

KPA 1: Accreditation Standards, Policies, and Procedures

• Develop, implement, and maintain pharmacy Standard Operating Procedures (SOPs), policies, and workflows to support specialty pharmacy accreditation requirements.
• Review and update policies and procedures to align with changes in accreditation standards and regulatory requirements.
• Collaborate with pharmacy leadership and staff to implement accreditation standards and ensure consistent adherence to established procedures.
• Provide training, education, and follow-up to pharmacy staff regarding accreditation standards and role-specific compliance requirements.
• Partner with the Training Coordinator to develop, review, and update training materials and quality assurance activities.
• Maintain accurate licensure records and tracking systems, including primary source verifications and required documentation.

KPA 2: Accreditation Surveys and Readiness

• Coordinate accreditation survey preparation activities to ensure pharmacy readiness and compliance with applicable standards.
• Prepare, organize, and maintain required documentation, policies, procedures, and supporting evidence for accreditation surveys.
• Support accreditation surveyors by responding to inquiries, providing requested documentation, and facilitating access to relevant information.
• Monitor and maintain regulatory and accreditation logs to ensure accuracy, completeness, and timely updates.
• Review staff-maintained logs and documentation to identify deficiencies and coordinate corrective actions.
• Track survey findings, corrective action plans, and follow-up activities to support continued accreditation compliance.

KPA 3: Regulatory Compliance and Documentation

• Monitor adherence to applicable federal, state, and local regulations, corporate policies, pharmacy SOPs, and accreditation standards.
• Track and verify completion of required departmental compliance training within established deadlines.
• Monitor continuing education and licensure requirements to support ongoing compliance.
• Maintain the confidentiality and security of patient and employee information in accordance with HIPAA and applicable privacy regulations.
• Collaborate with department leadership to ensure the proper collection, storage, retention, and destruction of Protected Health Information (PHI).
• Identify compliance gaps, communicate findings to appropriate stakeholders, and assist with implementing corrective actions.
• Complete additional compliance-related assignments and projects as directed.

KPA 4: Quality Assurance and Continuous Improvement

• Identify and recommend Quality Improvement Projects (QIPs) based on operational trends, compliance findings, and opportunities for process improvement.
• Develop and coordinate approved QIPs in collaboration with the Quality Management Committee (QMC).
• Collect, validate, and analyze quality improvement data to evaluate performance, identify trends, and measure outcomes.
• Monitor QIP documentation, track project milestones, and follow through on action items to ensure timely completion.
• Review pharmacy quality management events, investigate reported incidents, identify contributing factors, and coordinate resolution using established pharmacy best practices.
• Analyze quality management trends and recommend corrective and preventive actions to reduce recurring issues and improve pharmacy operations.
• Participate in AON's Quality Management Committee meetings and contribute to quality improvement initiatives, performance reviews, and action planning.
• Audit communication and documentation within CPR+, ONCO EMR, ORCA, and telephone systems to verify compliance with accreditation standards and documentation requirements.
• Communicate quality assurance findings and improvement recommendations to pharmacy leadership and relevant stakeholders.

Position Qualifications

Education

• High school education required.

Minimum Relevant Experience

• One year's experience in specialty, retail, mail order, or hospital pharmacy preferred.

Certifications/Licenses

• Active/Unrestricted Pharmacy Technician permit in the state of residence preferred.

Travel:  0%

Standard Core Workdays/Hours: Monday to Friday 9:00 AM – 5:30 PM EST.  Occasional overtime may be required, and weekend shifts based on location hours and operational needs.

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