Drug Diversion Prevention Coordinator

Under general direction, the Drug Diversion Prevention Coordinator is responsible for the oversight, coordination, and continuous improvement of the organization's drug diversion prevention, detection, investigation, and regulatory compliance program. This role collaborates with Pharmacy, Nursing, Human Resources, Compliance, Security, Patient Safety, and organizational leadership to identify, investigate, and mitigate risks associated with controlled substance diversion.

The coordinator utilizes data analytics, surveillance technology, audits, and investigations to ensure compliance with regulatory requirements, safeguard patients, support staff accountability, and strengthen controlled substance stewardship throughout the organization.

Program Management and Leadership Coordinate and maintain the organization's drug diversion prevention and monitoring program. Develop, implement, and periodically revise policies, procedures, and best practices related to controlled substance management and diversion prevention. Conduct diversion risk assessments and identify opportunities for process improvement.

Support and coordinate activities of the Drug Diversion Committee and Diversion Response Team. Serve as the organization's subject-matter expert on controlled substance diversion prevention and response. Lead initiatives to improve medication security, surveillance systems, documentation practices, and diversion prevention processes.

Surveillance, Auditing, and Analytics Monitor controlled substance procurement, dispensing, administration, wasting, reconciliation, overrides, and discrepancy reporting. Conduct routine audits and surveillance utilizing diversion monitoring software, automated dispensing cabinet reports, electronic health records, and other reporting tools. Analyze transactional data and utilization trends to identify actual or potential diversion activity.

Identify vulnerabilities within medication-use processes and recommend corrective actions. Develop and maintain key performance indicators and program metrics. Prepare reports, dashboards, and presentations for leadership, committees, and regulatory reviews.

Investigations Conduct and/or coordinate investigations involving suspected drug diversion incidents. Review discrepancies, reports, tips, documentation concerns, and unusual utilization patterns. Collect, organize, and maintain investigation documentation and evidence.

Collaborate with Pharmacy, Nursing, Human Resources, Compliance, Security, Legal, Employee Health, and leadership throughout the investigative process. Escalate concerns to the Diversion Response Team as appropriate. Support corrective action planning, monitoring, and follow-up activities.

Regulatory Compliance Ensure compliance with DEA, FDA, CMS, Joint Commission, state Board of Pharmacy, and other applicable federal and state regulations. Maintain documentation necessary for accreditation surveys, regulatory inspections, and internal audits. Stay current on emerging regulations, standards, and best practices related to controlled substances and diversion prevention.

Participate in regulatory inspections and organizational readiness activities. ​​​​​​​​​​​​​​ Education and Training Develop and deliver education programs on controlled substance handling, diversion prevention, reporting expectations, and medication safety. Educate staff, providers, and leaders regarding diversion risks, regulatory requirements, and best practices. Create educational materials, resources, and communication tools supporting safe medication management.

Present findings, trends, and recommendations to organizational leadership and committees. Collaboration and Quality Improvement Partner with nursing, pharmacy, anesthesia, compliance, patient safety, and operational leaders to promote a culture of accountability and patient safety. Participate in quality improvement, medication safety, and regulatory committees.

Lead or support root cause analyses and system improvement initiatives related to controlled substance management. Evaluate and recommend enhancements to diversion prevention technologies and monitoring systems. Perform other duties as assigned.

Education and

Bachelor's degree in Nursing, Healthcare Administration, Healthcare Compliance, Quality Management, or a related healthcare field. Current Registered Nurse (RN) license or equivalent healthcare credential required. ASHP Drug Diversion Certificate within 12 months of hire

Minimum three years of hospital or healthcare experience. Experience with medication management, controlled substance oversight, compliance, patient safety, quality improvement, auditing, investigations, pharmacy operations, or related functions. Experience analyzing healthcare data and identifying trends and opportunities for improvement.

Knowledge, Skills, and Abilities: Knowledge of federal and state controlled substance regulations, including DEA and Board of Pharmacy requirements. Understanding of medication-use systems, healthcare operations, and automated dispensing technology. Strong analytical, investigative, and critical thinking skills.

Advanced proficiency in Microsoft Excel and healthcare reporting tools. Excellent written, verbal, and presentation skills. Ability to work independently while effectively collaborating across departments.

Ability to maintain confidentiality and manage sensitive investigations professionally. Experience with electronic health records and diversion surveillance software preferred.

Five or more years of healthcare experience. Experience leading diversion investigations or controlled substance oversight programs. Experience developing policies, procedures, and staff education programs.

Experience with diversion surveillance technologies, including Bluesight (Protenus), Kit Check, Omnicell Analytics, or similar platforms. Experience with Power BI, Tableau, or other data visualization tools. Lean Six Sigma Green Belt or higher certification.

Day Shift · Mon-Fri 8a-4:30p