Qureos Mentor

Montage Health

<div><div>Welcome to Montage Health&rsquo;s application process!</div><div>
Job Description:</div><div>
The Clinical Pharmacy Specialist will perform duties in the following areas across all lines of business, including Utilization Management, Formulary Support, Appeals and Grievances, and Audit and Reporting Support to support the pharmacy team.</div><div></div><div>
This position will perform duties reviewing coverage for medications under the pharmacy and medical benefits for all lines of business necessary. The Clinical Pharmacy Specialist utilizes established company guidelines to review requests from physicians, medical groups, pharmacies, and members for the utilization of prescription drugs and pharmacy benefits. The specialist will conduct, research, and resolve any inquiries, problems, or issues in a timely manner.</div><div></div><div>
The Clinical Pharmacy Specialist is responsible for supervising and directing the support services needed for pharmacy services across all lines of business. This team member will continuously look for ways to improve processes and contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner.</div><div></div><div>
Responsibilities</div><div>
Utilization Management: Prior Authorization for Medical and Pharmacy Benefit (Medicare Part B and Part D; Commercial Plans)</div><ul><li>
Input, review and decision Medicare Part B requests for J codes, Q codes, and other medical benefits drugs/supplies.</li><li>
Track and triage coverage determinations and/or prior authorization requests submitted from providers and determine if a pharmacist review is required.</li><li>
Monitor prior authorization system to ensure turnaround times are met and contact providers for additional information to facilitate coverage determination reviews.</li><li>
Refer coverage determination requests for specialty drugs to a delegated vendor or client for processing when applicable.</li><li>
Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.</li><li>
Notify physicians, providers, and members of coverage determination request decisions.</li><li>
Oversight and preparation of correspondence, proposals, reports, spreadsheets, and forms.</li><li>
Assist in maintaining policies &amp; procedures, including editing, proofreading.</li><li>
Provide project management assistance to pharmacist and team as needed.</li><li>
Support member and provider calls regarding authorization, benefit inquiries, and resolution of pharmacy-related member questions as well as outbound customer service calls to members and delegated partners.</li><li>
Coordination and completion of intake/processing for pharmacy and medical authorization and appeal requests. Perform preliminary review for completeness and appropriate documentation. Triage and escalate to the appropriate clinical resource when needed.</li><li>
Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/consultation by a pharmacist.</li><li>
Support the pharmacist or Pharmacy Director with quality and STARS related measures, including outreach to members, providers, and pharmacies.</li></ul><div></div><div>
Formulary Support</div><ul><li>
Assist the Director in maintenance of the formulary and processing formulary change requests on a weekly basis.</li><li>
Support team in generating, maintaining, and reviewing Formulary Status Grids.</li><li>
Assist pharmacist in audits and quality checks on the current formulary status for accuracy and contract compliance.</li></ul><div></div><div>
Appeals and Grievances</div><ul><li>
Responsible for intake/entry and investigation/resolution of all prescription-related grievances received by the Plan or PBM</li><li>
Identify validity of appeal and send request to correct department as appropriate.</li><li>
Other appeal tasks as required.</li></ul><div></div><div>
Audit and Reporting Support</div><ul><li>
Assist pharmacist in a range of tasks necessary for pharmacy audit and recovery functions, including:<ul><li>
Perform audits and quality checks on active prior authorizations claims.</li><li>
Review paid claims for quantity and/or billing discrepancies.</li><li>
Investigate member complaints and documentation of findings according to Fraud Waste and Abuse (FWA) program.</li></ul></li><li>
Support pharmacist in monitoring delegated PBM functions through generation of reports and the review of reports such as daily rejected claims, in depth monthly review of approved and rejected claims, monthly review of posted/published formulary, monthly review of redeterminations and prescription related grievances, and Coverage Gap Discount discrepancy reports.</li><li>
Communicate or fax inquiries to pharmacies related to review findings and updates pharmacy database with incoming phone calls, faxes, and e-mails.</li><li>
Responsible for the maintenance of consistent processes and updating of policies and procedures and standard operating procedures as assigned.</li><li>
Assist pharmacist with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)</li><li>
Medicare Part D Operations, including:<ul><li>
Assist with identifying and correcting eligibility and group issues.</li><li>
Process member claims and pharmacy claims.</li><li>
Review and process Medicare Advantage Prescription Drug Event (PDE) data, such as:<ul><li>
Identification of errors with member eligibility, Low Income Subsidy Cost Sharing, as well as processing Institutional, ESRD and Hospice prescription drug claims.</li><li>
Monitor and report prescription drug metrics, including but not limited to, review of B versus D drugs, appropriate Copay and Deductible calculation, and corrective actions for informational and rejected PDE claims.</li></ul></li></ul></li></ul><div></div><div>
Other Responsibilities</div><ul><li>
Serve as a training resource for other team members and identifies and shares best practices.</li><li>
Provide administrative support to the Pharmacy Director for Committees chaired by Chief Medical Officer.</li><li>
Assist with pharmacy matters across all lines of business.</li><li>
Develop professional relationships with physicians, physician&rsquo;s office staff, medical management staff and/or pharmacists.</li><li>
Demonstrate understanding and accurate interpretation to support compliance with regulatory standards, e.g. Medicare Advantage and HIPAA.</li><li>
Prioritize and plan work for completion in a timely manner, coordinating with others as needed, and meeting deadlines set for all phases of work.</li><li>
Maintain a high level of professionalism, safeguarding and preserving the confidentiality of all information in accordance with HIPAA regulations.</li><li>
Demonstrate the ability to adapt to changes in the workload and responsibilities.</li><li>
Perform other activities and functions related to pharmacy or UM as delegated by the pharmacist or Pharmacy Director to evolve with business needs.</li></ul><div></div><div>
Experience</div><ul><li>
Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.</li><li>
Integrity: Consistently honors commitments and takes responsibility for actions and words.</li><li>
Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.</li><li>
Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.</li><li>
At least three years of experience in a health plan or PBM performing prior authorization for drugs, particularly Medicare Part B and Part D.</li><li>
Attention to details in obtaining complete and accurate information.</li><li>
Ability to key data accurately and efficiently.</li><li>
Ability to communicate effectively, including written and verbal communication skills.</li><li>
Bilingual in English and Spanish preferred.</li><li>
Business English and/or technical vocabulary related to health care industry (insurance/medical terminology).</li><li>
Basic knowledge of medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-10, CMS 1500, etc.).</li><li>
Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.</li><li>
Excellent phone manner and ability to handle multiple phone lines.</li><li>
Ability to identify and trouble-shoot problematic issues independently.</li><li>
Ability to follow clinical criteria and instructions to approve prior authorization requests.</li><li>
Must be able to meet established deadlines.</li></ul><div></div><div>
Education</div><div>
Minimum A.A. degree</div><div></div><div>
Licensure/Certifications</div><div>
License/Certification: Active Pharmacy Technician License required.</div><div></div><div>
Pay Rate: $30 per hour</div><div></div><div>
Equal Opportunity Employer</div><div></div><div>
Assigned Work Hours:</div><div>
Full time (remote)</div><div></div><div>
Position Type:</div>
Regular</div><div></div>

Clinical Pharmacy Specialist - Aspire Health

<div><div>Welcome to Montage Health&rsquo;s application process!</div><div>
Job Description:</div><div>
Under the leadership of the HIT Instructional Design and Communication Manager, the RN Epic Principal Trainer / Instructional Designer serves as the primary owner of end user education for assigned Epic and non Epic applications. This role is responsible for the design, development, maintenance, and governance of training curriculum, training environments, and education readiness for software implementations, upgrades, and optimization initiatives.</div><div>
The Instruction Designer partners closely with application analysts, operational leaders, Credentialed Trainers, and end users to ensure educational content accurately reflects validated workflows and supports safe, efficient, and effective system use across the organization.</div><div></div><div>
Responsibilities include but are not limited to:<br>
<ul><li>Serve as the Epic Principal Trainer for assigned applications, providing subject matter expertise in both technical functionality and operational workflows</li><li>Own the end user education strategy for assigned applications, including new hire, upgrade, and post implementation training</li><li>Act as the primary education liaison between application analysts and operational stakeholders</li><li>Ensure all training content aligns with Epic standards, organizational policies, and validated workflows</li></ul></div><div></div><div>
Curriculum Development and Instructional Design<br>
<ul><li>Design, develop, maintain, and govern comprehensive training curriculum and materials for Epic and non Epic applications</li><li>Translate complex workflows into clear, role based learning experiences using adult learning principles</li><li>Create engaging learning activities, exercises, simulations, and reference materials</li><li>Design and maintain assessments, quizzes, and competency measures to evaluate effective knowledge transfer</li></ul></div><div></div><div>
Training Environment Ownership<br>
<ul><li>Develop, test, validate, and maintain Epic Training Environments, including realistic patient builds and workflow driven scenarios</li><li>Ensure training environments accurately reflect production workflows and support curriculum objectives</li><li>Participate in testing and workflow validation of application changes prior to release into training and production environments</li></ul></div><div></div><div>
Credentialed Trainer (CT) Program Oversight<br>
<ul><li>Lead and oversee the Credentialed Trainer program for assigned applications</li><li>Train, coach, and support Credentialed Trainers and super users who assist with end user education</li><li>Monitor adherence to curriculum standards, workflow accuracy, and instructional quality</li><li>Support ongoing competency and readiness of Credentialed Trainers</li></ul></div><div></div><div>
Training Delivery and Support<br>
<ul><li>Conduct end user training as needed, particularly for specialty roles, go live support, or when Credentialed Trainers are unavailable</li><li>Provide education support during implementations, upgrades, and new version releases</li><li>Document education related issues and partner with application teams to address gaps</li></ul></div><div></div><div>
Online Learning and Continuous Improvement<br>
<ul><li>Oversee implementation and maintenance of online learning programs for assigned applications</li><li>Maintain fluency in instructional design trends, learning technologies, and Epic education best practices</li><li>Continuously evaluate and improve training effectiveness based on feedback and outcomes</li></ul>
<br>
HIT departmental responsibilities<br>
<ul><li>Maintain a strong focus on customer service, responsiveness, and end user experience</li><li>Communicate effectively with stakeholders through clear written and verbal communication</li><li>Troubleshoot and resolve technical or training related issues within scope</li><li>Demonstrate proficiency with HIT tools, applications, and processes</li><li>Follow departmental and organizational policies, procedures, and standard operating practices</li></ul></div><div></div><div>
Experience<br>
Required Experience:<br>
<ul><li>Instructional design and education program planning</li><li>Development of training curriculum and materials</li><li>Adult learning principles and knowledge transfer assessment</li><li>Classroom facilitation and learner coaching</li><li>Customer service and stakeholder engagement</li><li>Use of instructional design software (e.g., Snagit, Camtasia, Captivate or equivalent)</li><li>Microsoft Office applications</li></ul>
<br>
Preferred Experience:<br>
<ul><li>Epic Principal Trainer or Credentialed Trainer experience</li><li>Building, testing, and maintaining Epic Training Environments</li><li>Learning Management Systems and organizational learning platforms</li><li>Healthcare or clinical environment experience</li><li>IT issue tracking or ticketing systems (e.g., ServiceNow)</li></ul></div><div></div><div>
Education<br>
Bachelor&rsquo;s degree in healthcare, informatics, education, business, or information systems required.</div><div></div><div>
Licensure/Certifications<br>
<ul><li>Active Registered Nurse license; CA RN license due within 1 year of hire.</li></ul></div><div></div><div>
Required Post Hire:<br>
<ul><li>Epic certification(s) required within established timelines to support assigned applications and Epic version updates</li><li>Snagit and Camtasia certifications required within 90 days of hire and maintained as software versions change</li></ul></div><div><br>
Equal Opportunity Employer</div><div></div><div>
Salary Range (based on years of applicable experience)</div><div>
$150,696 to $201,552</div><div></div><div>
#LI-RL1</div><div></div><div>
Assigned Work Hours:</div><div>
Full time (exempt)</div><div></div><div>
Position Type:</div>
Regular<div></div><div>
Pay Range (based on years of applicable experience):</div>
$72.45<div>
to</div>
$96.90</div><div></div>

RN Epic Principal Trainer / Instructional Designer

Join Montage Health and explore 2   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Montage Health

About Company

Clinical Pharmacy Specialist - Aspire Health

RN Epic Principal Trainer / Instructional Designer