Director of Pharmacy Policy & Standards

BioMatrix Specialty Pharm

120d

About The Position

The Director of Pharmacy Policy & Standards is responsible for ensuring all company pharmacy locations maintain continuous compliance with all applicable pharmacy policies and accreditation standards. This role oversees audit readiness at all times, coordinates policy and accreditation activities, and collaborates closely with pharmacy operations leadership to ensure standards are integrated into daily operations. The Director of Pharmacy Policy & Standards is responsible for pharmacy standards and primary responsibilities include participating in and managing the policy and standards development/revision process, conducting regular site visits, providing educational instruction through standards workshops, and serve as the company’s subject matter expert in pharmacy accreditation and policy compliance. This position supports accreditation services staff in completing scheduled work on time in accordance with BioMatrix policies and procedures. The Director of Pharmacy Policy & Standards is an integral contributor in providing strategic oversight for all accreditation, policy and quality services. This includes participation in monitoring, evaluating, suggesting and implementing needed changes and continuous quality improvement. Provides strategic clinical oversight and expert guidance to executive and operational leadership, with accountability for directing the Performance Improvement and Quality Management Committee Program.

Requirements

• Graduate with a BS or Doctorate of Pharmacy from an ACPE-accredited School of Pharmacy required.
• Current, unrestricted license to practice pharmacy required.
• A minimum of five (5) years of experience in a healthcare organization with quality, compliance, and accreditation leadership required.
• Minimum of three (3) years of administrative experience developing and writing accredited applications and policies required.
• Demonstrated ability to develop, implement, and maintain policies and procedures that ensure regulatory compliance and operational efficiency.
• Proven experience managing multi-site accreditation efforts and maintaining continuous audit readiness.
• Has a deep knowledge of and experience with ACHC and/or URAC standards.
• Must have experience with sterile compounding and USP <797> and USP <800>.
• Strong knowledge of state and federal regulations that govern pharmacy (e.g., CMS, FDA, DEA, HIPAA, OSHA, Boards of Pharmacy).
• Excellent verbal, written, and presentation skills.
• Applies advanced problem-solving, judgment, and research skills to execute complex procedures and recommend actions in areas lacking established precedents or policies.
• Operates with significant autonomy in determining approaches, methodologies, and procedures within BioMatrix’s policy framework.
• Proficiency in Microsoft Office (including Word, Excel, PowerPoint, etc.).

Nice To Haves

• Experience with other accrediting bodies such as Joint Commission, NABP, etc. preferred.
• Experience at director or manager level in the infusion and/or specialty pharmacy industry preferred.
• Experience and a strong knowledge base in infusion therapies i.e. chronic, specialty, and acute therapies for both home and ambulatory infusion centers.

Responsibilities

• Develop policies and procedures based on accreditation standards, applicable laws, and best practice.
• Serve as the primary accreditation lead for all applicable pharmacy accreditation programs.
• Develop and deliver educations for pharmacy team and senior leadership.
• Review, interpret and implement Accreditation Standards.
• Discuss the findings with the applicants and BioMatrix in an educational manner.
• Draft and submit written executive summaries and present the findings to the senior leadership.
• Conduct required follow-up activities of applicants such as onsite reviews.
• Report any delay in the timely processing of applications to the Compliance and Privacy Officer as well as Vice President of Operations.
• Assist in providing technical support and advice to accrediting bodies and Standards Committees.
• Participate in Pharmacy standards development/revision process for the specific program.
• Partner with Pharmacy Operations leaders to embed accreditation requirements into standard workflows.
• Lead the development, maintenance, and approval process for all pharmacy-related policies and procedures.
• Manage accreditation and policy/procedure integration during new mergers or acquisitions, ensuring seamless compliance alignment.
• Plan, prepare, and lead internal audits and mock surveys; develop and oversee corrective action plans.
• Conduct regular on-site visits to pharmacy locations to verify compliance and provide operational support.
• Act as the primary liaison with accrediting organizations, responding to inquiries, preparing required documentation, and coordinating site surveys.
• Oversee Performance Improvement/Quality Management initiatives related to accreditation compliance.
• Provide regular reports to the Compliance & Privacy Officer on accreditation status, identified risks, and improvement initiatives.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 251-500 employees