The incumbent serves as a Program Analyst (Compliance) reporting to the Compliance Officer. The Program Analyst (Compliance) is responsible for program functions to include compliance education and training, compliance committee, internal reporting and communications, auditing and monitoring, investigation and response for highly-affiliated, tertiary care, 1B complexity health care delivery system.

Duties

The incumbent will perform a variety of duties, including but not limited to the following: Data Analysis (30%) Assisting the Compliance Officer in the formulation of major professional policies and procedures through completed staff studies, specific recommendations and professionally developed reports. Participating in systematic reviews of services. Assisting in developing, implementing or coordinating the implementation of corrective action resulting from such reviews. Establishing standards of a professional/administrative nature to improve program, services, operations, and facilities at all levels of the organization. Assisting the Compliance Officer in quality improvement programs. Working special projects and additional tasks by the Compliance Officer, which are of major importance for the facility's overall mission. Coordinating and preparing documents for programs or services which are required by the Joint Commission (TJC), the Inspector General, and other accrediting bodies. Program Management (50%) Working independently to coordinate all aspects of the Controlled Substance inspection program for all areas of CTVHCS that administers or stores controlled substances or other commonly diverted medications to ensure safety and control of inventory. Guaranteeing facility compliance with VHA directives, handbooks, local policy and procedures, and accrediting organization standards regarding the use of controlled substances. Recruiting, training, and maintaining an adequate number of Controlled Substance Inspectors (CSI). Organizing and ensuring completion of the required inventories and inspections by CSI in each are that stores commonly diverted and controlled substances. Providing and ensuring CSI completion of all training requirements including but not limited to national mandated training, CSI Certification, local training, and annual competencies. Serving as an authority on the Controlled Substance Inspection program and conducting training and education, written and/or oral, as independently determined, for pharmacy and nursing staff. Developing and making recommendations for written policies and procedures for inspection of controlled substances based on knowledge of mandated regulations and Controlled Substance Committee collaboration. Serving as the liaison between the facility and any accrediting/investigative body; e.g. TJC, OIG or SOARS regarding specific questions or concerns of the program. Reviewing all documented complaints recorded by the patient advocates, relating to possible diversion activities (e.g. shorted quantities, mail prescriptions not received, etc.). Preparing quarterly and annual reports to the Medical Center Director summarizing any identified discrepancies, trends and potential areas for improvement, including development and implementation of corrective action plans. Communication (10%) Communicating on a daily basis with members of CTVHCS facility leadership to include both Executive and Service level leadership. Developing collaborative working relationships at all levels. Providing leadership to groups and teams; and developing and presenting executive level reports for other committees and top management as necessary. Serving on committees in varying capacities including chairperson, voting participant and/or representative of the section. Staff Education (10%) Educating staff at all levels on the Compliance and Controlled Substance program concepts, initiatives and tools. Supporting and facilitating education and communication to engage front line staff in understanding program concepts and tools and their application in improving administrative and clinical processes. Identifying highlights and promotes compliance and controlled substance program successes and best practices throughout the health care system. Developing training material and makes presentations in various education forums, including new employee orientation and provider training. Work Schedule: 7:00am - 3:30pm; 7:30am - 4:00pm; 8:00am - 4:30pm Virtual: This is not a virtual position. Position Description/PD#: Program Specialist/674-8196-O Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not Approved Financial Disclosure Report: Not required

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/09/2023. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-09 position you must have served 52 weeks at the GS-07. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. You may qualify based on your experience and/or education as described below: Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Skills in the preparation, control and management of written and electronic communications; Using data to make recommendations to expedite and enhance process improvement studies, organizational change, and other organizational performance consultant studies; Coordinating with high level leaders and managers to develop effective project/program plans to resolve serious operations situations; Effectively expresses information to multiple audiences through clear, convincing oral and written communications; demonstrates logical thinking when describing facts and concepts, and shapes communications to meet the needs of a specific audience; actively listens to others and demonstrates understanding of their comments and/or questions. OR, Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have a Master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D. in a field which demonstrates the knowledge, skills, and abilities necessary to do the work of the position. OR, Combination: Applicants may also combine education and experience to qualify at this level. You must have an combination of specialized experience and education beyond 1 full year of graduate level education. You will be rated on the following Competencies for this position: Planning and Evaluation Oral Communications Problem Solving Writing Education and Training Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address VA Central Texas Health Care System 1901 Veterans Memorial Drive Temple, TX 76504 US
• Name: VISN 17 SSU USAS Group
• Email: [email protected]