Prescription Monitoring Program Team Lead - RN (Finance)

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

The Prescription Monitoring Program Team Lead is responsible for managing the assigned team to meet or exceed timeliness and quality standards for all program reporting and tracking. Responsible for training and mentoring of assigned team members as well as providing support to the Medical Director who has oversight for the program. This role performs clinical reviewer duties to include reviewing clinical records for identified TRICARE beneficiaries and providers to assess the need for intervention regarding the use and prescribing of controlled medications. Supports clinical quality efforts toward beneficiary safety and quality clinical practice by network providers and forwards appropriate cases to quality committees. The position influences ongoing assessment, development, and implementation of process improvements and identifies techniques for reporting and measuring outcomes.

Education & Experience

Required:

• Registered Nurse current unrestricted license in appropriate state or territory of the United States
• 5 years' experience in any combination of clinical practice, clinical review and intervention, pharmacy compliance management, or managed care
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• Hold a current certification from an industry recognized entity in Case Management, Healthcare Compliance, or Healthcare Quality or other appropriate credentials to review standard of care determinations
• Knowledge of training opportunities to support providers, such as state Prescription Drug Monitoring Programs (PDMP) and Substance Abuse and Mental Health Services Administration (SAMHSA) training
• Proficiency in Microsoft Office suite of applications and EHR systems to conduct extensive investigations
• Prior experience in a team lead, mentoring or training role

Preferred:

• Experience in clinical review practices specific to medication management, pharmacy, or healthcare compliance including preparing detailed compliance reports
• Experience analyzing and evaluating claims data, pharmacy records, and policy guidelines for compliance reviews
• Experience with TRICARE, VA, or other government benefit programs, particularly with prescription drug monitoring programs (PDMP) or the TRICARE Prescription Monitoring Program (PMP).
• Formal training in healthcare fraud detection

Key Responsibilities

• Provides training, guidance and support to PMP clinical and non-clinical staff.
• Uses management reports to prioritize and monitor the workload throughout the day and quarter (primary reporting requirements are quarterly, but intervening progress reporting is also required).
• Makes daily staff assignments and makes adjustments as needed throughout the day to meet contract requirements.
• Leads and Executes PMP Access and Review: accessing and receiving PMP databases/reports and reviewing patient and provider prescription history to identify patterns or discrepancies. Screens claims for medication line items that show potential over-utilization and medically inappropriate prescribing of controlled substances and reviews to establish the medical necessity for the controlled substances and reviews to establish the medical necessity for the controlled substances.
• Leads and Supports External Communication and Collaboration: Communicating findings to prescribers (doctors, nurse practitioners, etc.) to inform them of clinical decisions and promote appropriate prescribing practices.
• Leads Compliance and Advocacy Efforts: Ensuring compliance with Tricare-specific reporting requirements and PMP policies and procedures, advocating patient safety and promoting best practices in controlled substance prescribing.
• Leads development, refinement, and implementation of high-level compliance protocols, update of desk procedures, clinical guidelines, review processes, and training guides.
• Works with Medical Directors as needed when interventions are required and/or need to be escalated and serves as Subject Matter Expert for program for clinical and non-clinical staff questions regarding the program.
• Collaborates with the Defense Health Agency (DHA) and medical claims and pharmacy vendor partners to facilitate the required review of claims and medical records to assess for the need for intervention in circumstances of actual or potential drug abuse situations or medical provider over prescribing patterns.
• Conducts Data Analysis and Interpretation: Analyzing prescription data for red flags, such as multiple prescriptions, excessive quantities, or unusual prescribing patterns, to assess potential risk.
• Manages and Executes Reporting and Documentation: Documenting findings and any actions taken based on review, ensuring accurate record-keeping.

.:

• Conducts and manages program Case Management and Follow-up: Support case management of patients identified as potentially at risk, ensuring appropriate interventions and follow-up.
• Participate in special projects and cross-functional teams to identify and drive process improvement opportunities and techniques for measuring outcomes.
• Provides guidance for complex clinical issues and ensures compliance with contractual obligations.
• Performs audits as assigned and provides results to supervisor.
• Assists staff with reporting PQIs, critical findings, suspected fraud, HIPAA disclosures.
• Ensures staff adherence with defined department procedures.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources. Ability to provide staff direction in absence of supervisor.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-orientation to consider all relevant circumstances to enable sound decision making.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues. Apply clinical decision-making and established review criteria to assess complex clinical care situations. Applies clinical knowledge to make determinations for appropriate prescription use and provider prescribing patterns and prepares and presents more complex cases for Medical Director Review.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Supports staff in a positive manner. Works with other departments to resolve issues.

Technical Skills: Thorough knowledge of TriWest policies and procedures, TRICARE policy and contract requirements, Case Management, Utilization Management, Managed Care concepts, medical terminology, medical management systems, and protected health information. Proficiency with International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) classification systems, Uniform Billing Procedures, American Dental Association (ADA) coding, and common reporting measurements.

Working Conditions

Working Conditions:

• Availability to cover any work shift
• Works within a standard office environment, with infrequent travel required
• A private and secure workspace and workstation with high-speed internet is required
• Extensive computer work with long periods of sitting
• Department of Defense (DoD) security clearance required

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $99,000 - $110,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.