Reviews Part D coverage determinations and appeals to ensure clinical appropriateness and compliance with CMS regulations.
Conducts Medication Therapy Management (MTM) activities, including comprehensive medication reviews and targeted interventions for high-risk members.
Supports pharmacy quality improvement initiatives aligned with Medicare Star Ratings and HEDIS measures.
Alignment Health is a healthcare company focused on serving seniors and the chronically ill through Medicare Advantage plans. The company is fast-growing with a team of passionate people dedicated to transforming senior care.
Reviews, verifies, and interprets all physician orders received using the patient profile.
Screens medication orders for optimal usage, monitoring for allergies, interactions, and appropriate dosing.
Participates in continued education to meet regulatory requirements and organizational goals.
CommonSpirit Health is one of the nation's largest nonprofit Catholic healthcare organizations, delivering over 20 million patient encounters annually. With more than 157,000 employees, 45,000 nurses, and 25,000 physicians across 24 states, the organization focuses on creating a more just, equitable, and innovative healthcare delivery system.
Design and configure prior authorization criteria, decision trees, and authorization parameters within the PA system.
Perform quality assurance and quality control reviews to ensure clinical intent and regulatory compliance.
Collaborate with internal teams and external clients to support delegated PA services and system optimization.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. The company is a public benefit corporation focused on rebuilding trust in healthcare in the U.S., with a culture that emphasizes collaboration and client support.
Manage provider and clinic compliance relationships, including onboarding and edge case resolution for approximately 3,500 clinics.
Lead investigations into prescribing pattern anomalies and credential lapses, producing written summaries and communicating outcomes.
Build and deliver compliance training for the sales team and develop provider-facing educational materials.
Strive Pharmacy is a personalized compounding pharmacy focused on individualized care and genuine partnership with patients and providers. The company is growing and seeks people who share their conviction for a more human approach to healthcare.
Review and evaluate medication orders for accuracy, appropriateness, and safety.
Provide medication counseling and conduct patient care assessments to optimize drug therapy.
Collaborate with healthcare providers and participate in interdisciplinary team to monitor outcomes.
Shields Health Solutions is a healthcare company specializing in specialty pharmacy and therapy management services. They are an equal opportunity employer committed to diversity and inclusion.
Assists with patient medication management and facilitates medication renewal requests.
Acts as a liaison between providers, patients, and pharmacies for prescriptions and prior authorizations.
Monitors prior authorization status and updates relevant parties throughout the process.
Mass General Brigham is a not-for-profit integrated health care system supporting patient care, research, teaching, and community service. They employ a diverse team of professionals including doctors, nurses, and tech experts, fostering a collaborative culture focused on exceptional care.
Develop and deliver clinical messages to physicians, members, clients, and consultants.
Manage formulary strategy and clinical policy development across pharmacy and medical benefits.
Complete clinical prior authorizations and retrospective reviews.
Archimedes is a specialty drug management company that transforms the PBM industry by eliminating conflicts of interest and delivering rigorous clinical management. The company is expanding its team and focuses on cost management.
Respond to patient inquiries regarding prescription drug plan coverage and fulfillment through the pharmacy, including answering inbound calls and conducting status checks.
Make outbound patient refill phone calls, coordinate medication refills including data entry and pharmacy claim adjudication, and resolve adjudication error messages.
Manage, organize, and update relevant data using database applications, identify trends, and participate in process improvement initiatives.
Shields Health Solutions is a healthcare company that partners with health systems to deliver specialty pharmacy services. They focus on patient engagement and medication adherence through integrated care models.
Provide expert-level medication therapy consultations to patients and providers, including Medication Therapy Management (MTM) services like Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs).
Collaborate with the Engineering team and leadership to improve Arine's software platform and guide the Clinical Support team, while managing a consistent volume of patient interactions.
Meet individual and team performance metrics related to outreach, engagement, documentation quality, and clinical outcomes, and adapt to evolving clinical projects and assignments.
Arine is a rapidly growing healthcare technology and clinical services company that uses data science and AI to optimize medication management and reduce healthcare costs. The company manages over 18 million lives, was ranked #236 on the 2024 Inc. 5000 list, and has a strong culture focused on innovation and patient outcomes.
Lead and manage a team of Patient Engagement members to ensure timely medication refill support and high-quality patient care.
Proactively manage support in assigned hospitals and clinics to ensure patients receive medications on time and service level goals are met.
Provide ongoing coaching, performance management, and professional development to drive team success and adoption of best practices.
Shields Health Solutions provides patient engagement and pharmacy support services to hospitals and clinics. It is a fast-growing company with a focus on high quality and accountability.
Provide virtual or telephonic support to clients and healthcare professionals, documenting medical information requests and adverse events.
Conduct study compliance calls and enroll participants in educational seminars.
Maintain excellent quality and productivity standards while adhering to program scripts and guidelines.
Inizio Engage is a strategic, commercial and creative engagement partner specializing in healthcare. They employ over 7,000 experts in more than 20 countries, fostering a passionate, diverse, and global culture that challenges conventional thinking to improve health outcomes.
Collaborate with engineering, product, and data teams to develop and maintain the software platform and improve clinical algorithms.
Serve as a subject matter expert, triage bugs, and respond to clinical questions from providers, users, and leadership.
Conduct user acceptance testing, prepare customer demonstrations, and develop intervention strategies to optimize medication utilization.
Arine is a healthcare technology and clinical services company focused on optimizing medication management through a SaaS platform that combines data science, machine learning, and clinical expertise. Backed by leading healthcare investors, the company manages over 18 million lives and was ranked 236 on the 2024 Inc. 5000 list, fostering a collaborative and mission-driven culture.
Serve as the escalation resource for complex medication-interaction, dosing, and contraindication questions raised by the nursing team.
Advise on medical-cannabis pharmacology within an information-only scope (no prescribing, dispensing, or brand recommendations).
Support clinical protocol and quality review as requested while maintaining caller confidentiality and HIPAA compliance.
CLF Consultants is a federal contractor providing healthcare staffing and language access services across U.S. federal, state, and local agencies. Their network of over 500 healthcare professionals and 200 interpreters supports nationwide coverage.
Provide virtual or telephonic medical information support to customers, patients, and healthcare professionals.
Ensure compliance with FDA regulations, pharmacovigilance requirements, and company procedures.
Document and escalate information requests, adverse events, and product quality complaints accurately.
Inizio Engage is a pharmaceutical services provider that delivers medical information, patient support, and pharmacovigilance solutions. The company fosters a diverse, inclusive culture with a focus on compliance and quality.
Conduct research and quality assurance for drug and biological policies.
Write business logic and translate industry references into Cotiviti policy.
Mentor new team members and assist with customer inquiries regarding clinical rules.
Cotiviti is a healthcare analytics company that provides clinical coding and policy solutions for health plans. They focus on maintaining accurate medical policy libraries and employ a global team, offering benefits like PTO and paid family leave.
Provide medication management services inclusive of medication access, education, adherence, and comprehensive medication management for pediatric patients.
Act as liaison between the designated region and the medication management center of excellence, ensuring compliance with all regulatory authorities.
Document encounters in the electronic medical record and promote evidence-based, cost-effective medication management.
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group reimagining care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care, working alongside families, providers, and health plans, with a focus on compassion and an unwavering commitment to children with medical complexity.
Lead and manage a team of Patient Support Associates, providing coaching and performance development.
Ensure medication access through refills, prior authorizations, and financial assistance.
Oversee pharmacy workflows, conduct system audits, and collaborate with hospital stakeholders.
Shields Health Solutions specializes in specialty pharmacy services and patient support for hospitals and clinics. The company fosters a culture of patient-focused care and team collaboration, with a remote and onsite workforce.
Responsible for aiding in the delivery of clinical interventions and Medication Therapy Management (MTM) services for commercial and Medicare members.
Conducts telephonic and video chat outreach to complete analysis of members' medication regimens.
Performs outbound calls to members, fielding inbound calls, and facilitating communication regarding clinical programs.
Navitus is an alternative to traditional pharmacy benefit manager (PBM) models, committed to removing cost from the drug supply chain to make medications more affordable. The company has a team that celebrates diversity, fosters creativity, and encourages growth.