Prescription Monitoring Program Team Lead - RN

TriWest Healthcare Alliance - Phoenix, AZ

Job Title: Prescription Monitoring Program Team Lead - RN

Position: Team Lead responsible for managing the Prescription Monitoring Program

Job Type: Remote

Pay: $99,000 - $110,000 per year

Shift: Availability to cover any work shift

Work Type: Remote

Location

Address:

City: Phoenix

State: AZ

ZIP Code:

Job Responsibilities

Manage assigned team to meet or exceed timeliness and quality standards for program reporting and tracking.
Train and mentor assigned team members.
Support the Medical Director with oversight for the program.
Perform clinical reviewer duties including reviewing clinical records for TRICARE beneficiaries and providers.
Assess the need for intervention regarding controlled medications.
Support clinical quality efforts for beneficiary safety and promote quality clinical practice.
Forward appropriate cases to quality committees.
Influence ongoing assessment and development of process improvements.
Identify techniques for reporting and measuring outcomes.
Provide training, guidance, and support to PMP clinical and non-clinical staff.
Utilize management reports to prioritize and monitor workload.
Make daily staff assignments and adjust as needed to meet contract requirements.
Access and review PMP databases/reports to identify prescribing patterns.
Screen claims for medication line items showing potential over-utilization.
Communicate findings to prescribers to promote appropriate prescribing practices.
Ensure compliance with Tricare reporting requirements and PMP policies.
Lead development and implementation of compliance protocols and clinical guidelines.
Collaborate with DHA and other partners regarding claims and medical records.
Analyze prescription data for red flags regarding potential risk.
Document findings and actions based on reviews.
Support case management of patients identified as potentially at risk.
Participate in special projects and drive process improvement opportunities.
Provide guidance for complex clinical issues and ensure compliance.
Perform audits and provide results to supervisor.
Assist staff with reporting PQIs and suspected fraud.

Required Skills

Core Skills

Registered Nurse license
Proficiency in Microsoft Office and EHR systems
Ability to analyze data and provide clinical decision-making

Preferred Skills

Experience in clinical review practices related to medication management
Experience with TRICARE and government benefit programs
Formal training in healthcare fraud detection

Requirements

Experience: 5 years in clinical practice, clinical review, pharmacy compliance management, or managed care

Education: Registered Nurse current unrestricted license in appropriate state or territory of the United States

License & Certification:

Certification in Case Management
Certification in Healthcare Compliance
Certification in Healthcare Quality

Schedule:

Not specified

COVID-19 Requirements: Not Specified

Benefits

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

Supplemental Pay

Frequent pay raises
Overtime opportunities
Recognition and reward programs

Special Notes

US citizenship and favorable DOD background investigation required.
Veterans, Reservists, Guardsmen and military family members encouraged to apply.
TriWest Healthcare Alliance is committed to diversity and inclusion.