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Exemption Status:

Exempt

Schedule Details:

Sunday through Saturday

Scheduled Hours:

Mainly 8 hours on Weekdays during days; but requires some availability on evenings and weekends as needed

Shift:

1 - Day Shift, 8 Hours (United States of America)

Hours:

32

Cost Center:

24050 - 3800 Pharmacy

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Under the direction of the Pharmacy management team, this position is responsible and accountable for managing the day-to-day activities involved with maintaining compliance with USP <795>, USP <797>, and USP <800> standards, as well as MA Board of Registration in Pharmacy regulations at the UMass Memorial Health Care Community Hospitals’ Pharmacy Departments. Presents Personnel Monitoring (PM) and Environmental Monitoring (EM) findings/reports and develops recommendations for corrective action plans to the Pharmacy management team. Develops sterile and non-sterile compounding related training in collaboration with the management team. Provides department or individual education on sterile and non-sterile compounding operations, IV retraining, and Environmental Monitoring remediation.

Major Responsibilities:

• Performs, tracks, and monitors Personnel Monitoring (PM) in accordance with USP <797> regulations for all assigned pharmacy employees.  Develops recommendations for corrective action plans.  Presents findings and recommended corrective actions to the Pharmacy management team.
• Performs, tracks, and monitors Environmental Monitoring (EM) in accordance with USP <797> and USP <800> regulations for all assigned pharmacy sterile compounding facilities.  Develops recommendations for corrective action plans.  Presents findings and recommended corrective actions to the Pharmacy management team.
• Works with the Pharmacy management team to coordinate and perform IV retraining and Environmental Monitoring remediation based on corrective action plans.
• Develops and plans sterile and non-sterile compounding related training and monitoring activities at assigned pharmacies in collaboration with the Pharmacy management team.
• Serves as the principle trainer and educator for sterile compounding operations at assigned pharmacies.
• Develops and maintains a Quality Assurance Plan for sterile compounding activities to ensure state of control across all assigned sterile compounding facilities.
• Provides sterile compounding PM and EM report outs to the community entity Infection Control Committees at an interval determined by the Pharmacy management team.
• Provides guidance and recommendations for sterile compounding facility design, workflow, policies, procedures and documentation across all assigned pharmacies.
• Tracks compliance with IV room documentation and works with the Pharmacy management team to follow-up on missed or incomplete documentation.
• Builds and validates compounding records for batch documentation as needed.
• Participates in the evaluation and review of Quality Control Reports and Data from established 503B vendors.
• Participates in departmental preparation for sterile compounding related regulatory agency visits and serves as an on-site resource during regulatory agency inspections as needed.
• Provides recommendations to the Pharmacy management team on Nursing education for USP <797> compliance.
• Provides recommendations to the Pharmacy management team on IV room supplies and works with the Pharmacy Purchasing Coordinator to monitor and maintain par levels.
• Communicates sterile compounding procedural changes and best practices to pharmacy staff as needed.

Position Qualifications: