Prescription Monitoring Program Team Lead - RN

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.

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.

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.