Drug Diversion Compliance Manager

## Position Summary
Please note, target start date in mid November

The Manager of Corporate Drug Diversion Prevention Compliance supports the Director in leading and advancing the organization’s enterprise-wide drug diversion prevention program. This role ensures compliance with federal and state regulations, proactively identifies risks, and implements strategies to prevent, detect, and respond to drug diversion across facilities, outpatient clinics, and physician practices.

The Manager is expected to function with a high degree of independence and professional judgment, serving as a subject matter expert in drug diversion prevention, controlled substance oversight, medication management, patient safety, and related regulatory compliance requirements.

Key Responsibilities

- Assist the Director in overseeing the development, implementation, and continuous improvement of the enterprise-wide drug diversion prevention program.
- Serve as a subject matter expert in drug diversion prevention, controlled substance oversight, medication management, patient safety, and related regulatory compliance requirements.
- Analyze, interpret, and apply federal and state laws, regulations, accreditation standards, and agency guidance related to controlled substances, medication management, drug diversion prevention, and patient safety. Assess regulatory changes, determine organizational impact, and recommend risk mitigation strategies.
- Maintain up-to-date knowledge of evolving federal and state regulations, accreditation standards, enforcement trends, and industry best practices applicable to drug diversion prevention and medication management.
- Conduct risk assessments and audits across all care settings, including hospitals, outpatient facilities, ambulatory sites, and physician practices.
- Monitor and analyze data from automated dispensing systems, electronic health records (EHRs), drug diversion software, and other data sources to identify diversion risks, trends, and opportunities for program improvement.
- Conduct and co-lead investigations of suspected diversion incidents in collaboration with Corporate Security, Human Resources, Pharmacy, Nursing, Medical Staff leadership, Infection Prevention, Legal/Risk Management, and other stakeholders. Recommend corrective actions as appropriate.
- Ensure investigations are thoroughly documented and maintained in accordance with organizational, legal, regulatory, and confidentiality requirements.
- Provide regulatory and compliance guidance to operational leaders in the development, revision, and implementation of policies, procedures, controls, and monitoring activities related to controlled substance management, diversion prevention, medication safety, and regulatory compliance.
- Develop reports, dashboards, and key performance indicators (KPIs) to monitor program effectiveness, identify emerging risks, and support leadership decision-making.
- Research industry best practices, regulatory trends, enforcement actions, and evidence-based approaches to strengthen the organization's drug diversion prevention program.
- Develop and deliver education and awareness programs related to diversion prevention, reporting obligations, medication security, and regulatory requirements.
- In collaboration with the Director and appropriate stakeholders, evaluate and facilitate reporting to regulatory agencies, licensing boards, law enforcement, and other external entities when required.
- Coordinate and facilitate Drug Diversion Committee meetings, including agenda development, meeting minutes, action item tracking, and follow-up.
- Collaborate with hospital, ambulatory, physician practice, pharmacy, nursing, home care, hospice, and other clinical leaders to promote a consistent enterprise-wide approach to diversion prevention, detection, investigation, reporting, and corrective action.
- Perform other duties as assigned by the Director.

- NJ licensed Pharmacist or NJ RN licensure (MSN preferred)
- Minimum of 5-10 years’ experience in nursing or pharmacy within an acute or subacute healthcare setting.
- Minimum 3–5 years of experience in healthcare compliance, clinical or pharmacy operations, or drug diversion prevention programs.
- Drug diversion professional certification developed by American Society of Health -System Pharmacist ( ASHP) & International Health Facility Diversion Association ( IHFDA) is required within 18 months of hire.
- Strong knowledge of federal and state regulations related to drug diversion, including DEA, FDA, CMS Conditions of Participation, and NJ regulations related to medication management and controlled substances.
- Compliance Certification required within 24 months of hire
- Proficient or knowledgeable in automated dispensing systems (e.g., Omnicell, Pyxis), EHRs, and data analytics tools.
- Excellent communication, investigative, and problem-solving skills.

Work Environment

Hybrid or on-site depending on organizational needs. Occasional travel to hospitals, clinics, and physician practices may be required.