Prescription Monitoring Program Clinical Reviewer (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 (PMP) Clinical Reviewer reviews clinical records for identified TRICARE beneficiaries and providers to assess the need for intervention regarding the use and prescribing of controlled medications. Reviewer conducts reviews to identify potential over-utilization and medically inappropriate prescribing of controlled substances and inconsistencies with utilization for given medical diagnoses and develops support plans as indicated. This role directly supports clinical quality efforts toward beneficiary safety and quality clinical practice by network providers and forwards appropriate cases to quality committees and influences ongoing assessment, development, and implementation of process improvements and techniques for reporting and measuring outcomes.

Education & Experience

Required:

• Registered Nurse with current unrestricted license in appropriate state or territory of the United States, preferably with multi-state privileges
• 5+ years clinical experience; two of the five years in Utilization Management
• 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
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and Outlook) and medical management and electronic medical record systems
• Demonstrates effective verbal and written communication skills

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

• Collaborate 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.
• Accessing and Receiving PMP databases/reports and reviewing patient and provider prescription history to identify patterns or discrepancies.
• Analyzing prescription data for red flags, such as multiple prescriptions, excessive quantities, or unusual prescribing patterns, to assess potential risk.
• Communicating findings to prescribers (doctors, nurse practitioners, etc.) to inform clinical decisions and promote appropriate prescribing practices.
• Documenting findings and any actions taken based on PMP review, ensuring accurate record-keeping.
• Utilize excellent written and verbal communication skills to document the clinical review in the medical management system (MMS), including documentation reviewed, justification, and recommended interventions, which are carried forward in quality compliance reports to the government.
• Ensure ongoing compliance with TRICARE requirements as established in TRICARE policy and according to contract.
• Demonstrate thorough clinical decision making, exercise critical thinking skills both independently and in collaboration with other relevant departments or clinical leaders to meet strict deadlines with minimal supervision.
• Participate in the development, refinement, and implementation of compliance protocols, update of program desk procedures, clinical guidelines, review processes, and training guides.
• Ensuring compliance with TRICARE-specific reporting requirements and program policies and procedures, advocating for patient safety and promoting best practices in controlled substance prescribing.
• May also be involved in case management of patients identified as potentially at risk, ensuring appropriate interventions and follow-up.
• Prepares cases for Medical Director and Peer Review according to established policy.
• Refers potential quality issues and complaints to Clinical Quality Management.
• Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
• Maintain compliance with Federal, State and accreditation organizations.
• Participate in special projects and cross-functional teams.
• 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.

Information Management: Ability to obtain and manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

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

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; possess a realistic understanding of relevant issues. Apply clinical decision-making and established review criteria to assess complex clinical care situations.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, TRICARE policy, working knowledge of 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 work any shift
• Works remote, with infrequent travel
• A private and secure workspace and workstation with high-speed internet is required
• Extensive computer work with prolonged sitting
• Department of Defense 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.

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 $86,000 - $96,000 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.