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The Regulatory & Accreditation Pharmacist is responsible for supporting organizational compliance with federal, state, and local regulatory requirements, accreditation standards, and pharmacy practice guidelines across the healthcare system. This position serves as a key resource for medication-use compliance, accreditation readiness, policy management, audit coordination, and performance improvement initiatives related to pharmacy operations.

The Regulatory & Accreditation Pharmacist collaborates with pharmacy leadership, nursing, medical staff, quality, infection prevention, risk management, compliance, and operational departments to ensure adherence to standards established by organizations such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Florida Board of Pharmacy, Drug Enforcement Administration (DEA), United States Pharmacopeia (USP), and other applicable regulatory agencies.

Essential Duties and Responsibilities

Regulatory Compliance

• Monitors and interprets applicable federal, state, and local regulations impacting pharmacy operations and medication management.
• Ensures compliance with accreditation standards and regulatory requirements, including but not limited to The Joint Commission, CMS Conditions of Participation, DEA regulations, USP chapters, and state board requirements.
• Conducts routine compliance rounding, audits, tracer activities, and mock surveys throughout pharmacy and clinical areas.
• Assists in developing corrective action plans and monitoring compliance improvements.
• Maintains regulatory documentation, records, policies, and evidence of compliance.
• Supports controlled substance diversion prevention and monitoring initiatives.
• Participates in internal investigations related to medication-use compliance concerns.

Accreditation & Survey Readiness

• Coordinates pharmacy readiness activities for accreditation and regulatory surveys.
• Serves as a pharmacy liaison during regulatory inspections and accreditation visits.
• Assists with preparation and response to survey findings, plans of correction, and follow-up activities.
• Supports organization-wide medication management compliance initiatives.
• Maintains ongoing knowledge of evolving accreditation standards and communicates operational impacts to leadership.

Policy & Procedure Management

• Develops, reviews, revises, and standardizes pharmacy policies, procedures, and guidelines.
• Ensures policies align with current regulatory standards, evidence-based practices, and organizational expectations.
• Collaborates with multidisciplinary stakeholders on policy implementation and education.

Quality & Performance Improvement

• Participates in medication safety, quality improvement, and patient safety initiatives.
• Tracks, trends, and analyzes compliance and quality metrics.
• Assists with root cause analyses, event reviews, and action plan development.
• Supports medication-use evaluations and process improvement activities.

Education & Training

• Provides education and guidance to pharmacy staff and interdisciplinary teams regarding regulatory and accreditation requirements.
• Assists with onboarding and annual competency activities related to compliance standards.
• Develops educational materials and compliance communications.

Collaboration & Leadership

• Collaborates with pharmacy leadership and operational teams to support regulatory initiatives and operational excellence.
• Participates in committees related to medication management, patient safety, accreditation, and compliance.
• Serves as a subject matter expert for pharmacy regulatory and accreditation standards.
• Supports strategic initiatives and special projects as assigned.

Qualifications

Education

• Doctor of Pharmacy (PharmD) degree from an accredited college or school of pharmacy required.

Licensure / Certification

• Current unrestricted pharmacist license in the State of Florida required.
• Board certification (e.g., BCPS) preferred.
• ASHP residency training preferred.

Experience

• Minimum of 3–5 years of hospital pharmacy experience required.
• Experience with regulatory compliance, accreditation, medication safety, quality improvement, or pharmacy operations preferred.
• Experience supporting Joint Commission, CMS, or other accreditation surveys strongly preferred.

Knowledge, Skills, and Abilities

• Strong knowledge of hospital pharmacy regulations, accreditation standards, and medication management requirements.
• Knowledge of USP standards, DEA regulations, CMS Conditions of Participation, and state pharmacy laws.
• Ability to interpret and apply complex regulatory requirements.
• Strong organizational, analytical, and problem-solving skills.
• Excellent verbal and written communication skills.
• Ability to manage multiple priorities and deadlines.
• Ability to work collaboratively with interdisciplinary teams.
• Proficiency in Microsoft Office applications and pharmacy information systems.
• Strong attention to detail and commitment to operational excellence.

LI-PI1

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the groundbreaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status: Full time
Employee Type: Staff