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System Manager, Clean Rooms and Compliance

Medical University of South Carolina

Medical University of South Carolina

Charleston, SC, USA
Posted on Wednesday, June 21, 2023
  • R-0000014964
  • Charleston, South Carolina
  • Management-Clinical
  • Clinical & Research Support Services
  • Full Time

Job Description Summary

Position Description:
1. Purpose:
• The Pharmacy Manager provides operational and compounding and clean room compliance leadership and oversight to the Pharmacy Services ICCE and reports directly to the System Director of Medication Use and Standards, Medication Safety and Compliance. Responsibilities include oversight and monitoring of all compounding and clean room activities across the system. Additional responsibilities include collaborating with interdisciplinary team members to optimize the delivery of care, ensuring relevant safety, regulatory, certification and/or accreditation standards are maintained, and various required human resource functions.
2. Requirements:
o KNOWLEDGE, SKILLS, AND ABILITIES (Include physical and mental demands of the position-attach demands checklist if necessary):
 Doctor of Pharmacy degree and completion of a pharmacy residency program or equivalent experience.
 Minimum of 5 years Pharmacist experience with management or supervisory experience preferred
o LICENSES, CERTIFICATIONS (If applicable to position):
 SC Pharmacist License within 90 days of hire
 BLS Certification within 90 days of hire


Medical University Hospital Authority (MUHA)

Worker Type


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CC004415 SYS - ICCE - Pharmacy

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Job Description

Compliance and Quality Improvement

  • Actively participates in process improvement and quality related initiatives across the system, leading the system quality committee for compounding and clean room management
  • Develops KPIs and monitors performance metrics
  • In collaboration with pharmacy leadership team members, develops, evaluates and revises departmental policies and procedures.
  • Serves as the content expert in compounding standards
  • Works with other departments (e.g. Information Solutions, facilities) on system enhancements to uphold compliance standards.
  • Manages Assessments of Risk for Hazardous medications (Sterile and non-sterile) in collaboration with pharmacy leaders and the drug information team


Staff Development, Education, and Training

  • Assess practice gaps in pharmacy activities
  • Identify learning needs
  • Develop and support initial and required (e.g. annual) compounding training and education for the department
  • In collaboration with local pharmacy leadership, ensures staff members are trained and able to demonstrate the knowledge and skill necessary to provide compounding services upon hire and at least annually
  • Serve as the content expert in compounding standards and clean room management
  • Provides pharmacy in-service education when needed or requested
  • Participates in the education activities of the department and shows evidence of such
  • Precepts pharmacy and pharmacy technician students and/or residents during rotations.



  • Serves as the liaison between each pharmacy and the Pharmacy ICCE Leadership team.
  • In collaboration with local pharmacy leaders, enforces departmental policies and procedures and ensures compliance with pertinent state and federal laws and regulations, including but not limited to Joint Commission, USP, and SC Board of Pharmacy.
  • Ensures satisfactory relationships with other departments.
  • Facilitates solutions to problems and resolves complaints regarding departmental services and activities.
  • Sets example for other pharmacists and technicians in work quality, efficiency, productivity, and personal conduct standards.
  • Participates on departmental, medical center and system committees.
  • Attends required meetings and trainings


Drug Distribution

  • Routinely works side-by-side with pharmacy team members involved in compounding practices at each facility to observe, coach team members and identify needs.
  • Collaborates with other pharmacy ICCE leadership to ensures compliance with controlled substance policies and procedures according to DHEC and DEA regulations for associated areas, when used in sterile compounding
  • Routinely audits compounding areas and clean rooms at all facilities for compliance with departmental policies and procedures and pertinent state and federal laws and regulations


Additional Job Description

Education: Bachelor's Degree or Equivalent Work Experience: 8 years progressive work experience and 3 years management experience

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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