PacificSource Health Plans

Role Description Responsible for the preparation of GAAP, statutory, and regulatory financial reporting for PacificSource and Subsidiaries and for executing the recurring income tax provision and compliance cycle across a group of affiliated regulated insurance entities operating in multiple states and lines of business. This role reports to the Manager, Accounting & Regulatory Reporting and works under the functional direction of the VP, Controller on tax matters. - Prepare monthly internal GAAP financial statements and the management reporting package for PacificSource and Subsidiaries. - Prepare quarterly and annual NAIC statutory statements and applicable state-required financial reports for the group's regulated entities. - Prepare risk-based capital (RBC) calculations, capital projections, and other regulatory filings for applicable entities under supervision of the Manager, Accounting & Regulatory Reporting. - Consolidate and analyze financial results across the group's entities in support of internal, statutory, and regulatory reporting. - Contribute substantively to annual external CPA statutory audits and ad-hoc regulatory financial examinations, preparing requested schedules and responding to auditor and examiner inquiries. - Prepare, review, and post month-end journal entries, including entries supporting consolidation, for internal GAAP and statutory financial statements. - Maintain and apply specialized statutory (SAP) accounting knowledge and serve as a resource to the broader team. - Prepare quarterly and annual income tax provisions on both GAAP (ASC 740) and statutory (SSAP 101) bases for the consolidated group, including deferred tax computations, effective tax rate reconciliation, and the statutory deferred tax asset admissibility analysis, under supervision of the VP, Controller. - Own the income tax compliance workpaper-preparation and engagement-coordination process with external CPA firms: gathering data, preparing supporting schedules, and managing deliverables and timelines for the consolidated federal return and multiple state and local income tax filings across the group's jurisdictions. - Prepare and coordinate recurring indirect and local tax filings and associated GAAP accruals, including premium tax, sales and use tax, business and occupation tax, and business personal property declarations across applicable jurisdictions. - Prepare estimated income tax payment calculations and supporting schedules. - Research and respond to tax notices and agency correspondence, and support tax planning analysis. - Prepare, review, and post tax-related journal entries and accruals. - Develop reports and perform validation and user-acceptance testing for Workday changes affecting reporting and tax processes. - Identify and implement process improvement and automation opportunities across reporting and tax workflows, in partnership with the finance technology function. Qualifications - Minimum of 5 years of progressively responsible accounting experience. - Insurance statutory and regulatory reporting experience strongly preferred. - Hands-on income tax provision experience (ASC 740 and/or SSAP 101) strongly preferred. - Bachelor’s degree in Accounting or Finance required. - CPA license preferred but not required. Requirements - Advanced proficiency in Microsoft Excel. - Ability to work independently from established workpapers and processes. - Strong critical thinking and problem-solving skills. - Familiarity with statutory (SAP) accounting, income tax provision (ASC 740 / SSAP 101), and multi-jurisdiction tax compliance concepts. - Comprehensive understanding of GAAP and general accounting and business practices. - Proficiency in ERP/accounting software (Workday experience a plus). - Strong organizational skills, attention to detail, and clear written and verbal communication. Benefits - Base Range: $74,601.93 - $126,822.77. Company Description - PacificSource is an equal opportunity employer. - Values the diversity of our community, including those we hire and serve. - Committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected, and responded to.

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims. • Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures. • Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary. • Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary. • Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities. • Attend and participate in regional FWA Task Force and other state or federal meetings. • Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies. • Ensure regulatory reporting is developed, accurate, and submitted timely. • Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA. • Develop and conduct internal FWA related training. • Collaborate with government agencies during audits, investigations and Requests for Information (RFI). • Present and discuss case findings and recommendations in case review meetings with department and company management. • Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board. • Coordinate and manage the production of investigative materials in support of settlement negotiations.

• Design, implement, and manage the company’s FWA Program. • Provide expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints. • Analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership. • Track and report company activities to ensure compliance with state and federal FWA requirements. • Build and maintain a structure around an FWA and payment integrity program supported by policies, processes, procedures, workflows, and technology. • Develop and maintain FWA policies and procedures and implement a comprehensive FWA program. • Chair the Program Integrity Committee and collaborate on the development of the annual work plan. • Develop and maintain an FWA log and tracking system. • Proactively and independently research FWA issues and effectively employ investigative resources/techniques. • Maximize recoveries and avoidance for Medicare and Medicaid claims payments. • Develop disclosure strategies for potential fraud activities to various agencies.

• The FWA Program Manager will be primarily responsible for the design, implementation, and management of the company’s FWA Program, providing expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints. • The role will analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership on matters related to FWA compliance. • The program manager will track and report company activities to ensure compliance with state and federal FWA requirements.

Role Description The FWA Program Manager will be primarily responsible for the design, implementation, and management of the company’s FWA Program, providing expertise to staff in developing processes for tracking, investigating, and managing suspected FWA complaints. The role will analyze, report and monitor the FWA prevention efforts and provide recommendations to leadership on matters related to FWA compliance. The program manager will track and report company activities to ensure compliance with state and federal FWA requirements. - In collaboration with the Corporate Compliance Officer and other business unit leaders, build and maintain a structure around an FWA and payment integrity program supported by policies, processes, procedures, workflows, and technology. - Develop and maintain FWA policies and procedures and implement a comprehensive FWA program. - Chair the Program Integrity Committee and collaborate on the development of the annual work plan which will outline and detail the annual FWA audit and monitoring plan. - Develop and maintain an FWA log and tracking system. - Proactively and independently researches FWA issues and effectively employ investigative resources/techniques. - Maximize the recoveries and avoidance for Medicare and Medicaid claims payments with a demonstrated ability to achieve results. - Work to develop prospective and retrospective fraud and abuse detection, investigation, recovery and avoidance through the use of data sources for data mining and analytics to proactively seek out outlying claims activities and investigate for fraud, waste, and abuse. - Develop, translate, and execute strategies or functional/operational objectives for the company with regard to fraud, waste, and abuse. - Responsible for notification of MEDIC of potential fraud activities. - Responsible for notification of state and other federal agencies of potential fraud activities. - Assist in the development and presentation of FWA training presentations. - Serve as primary point of contact for external oversight agencies to include the MEDIC and OHA Medicaid Fraud Unit. - Serve as a member of the Corporate Compliance Committee reporting on FWA matters across all lines of business. - Responsible for creating and presenting FWA reports to the Audit and Compliance Committee of the Board. - Manage and oversee the preparation and submission of FWA regulatory reporting requirements to CMS and OHA. - Regularly attend fraud related meetings with OHA. - Responsible for oversight, management, development, implementation, and communication of the FWA program. Qualifications - Minimum of 8 years related experience in fraud, waste, and abuse investigations, payment integrity processes, and data mining and analysis of health care claims. - Minimum of 4 years of experience implementing or maintaining a fraud, waste, and abuse and payment integrity program in health care. - Experience with regulatory agency reporting and interaction as it relates to fraud, waste, and abuse. - Minimum 4 years of related experience with Medicare and/or Medicaid programs required. Requirements - Bachelor’s degree in business, management, health care administration or other related field or Associate’s degree and equivalent work experience required. - Master’s degree in business, management, or health care administration preferred. - Fraud examiner certification preferred. Benefits - Base Range: $83,310.45 - $145,793.28 Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 10% of the time. Skills - Accountability - Collaboration - Communication (written/verbal) - Flexibility - Listening (active) - Organizational skills/Planning and Organization - Problem Solving - Teamwork Physical Requirements - Stoop and bend. - Sit and/or stand for extended periods of time while performing core job functions. - Repetitive motions to include typing, sorting and filing. - Light lifting and carrying of files and business materials. - Ability to read and comprehend both written and spoken English. - Communicate clearly and effectively.

Role Description The Senior Investigator manages work related to fraud, waste and abuse audits and investigations across several independent and specialized teams. Functions include: - Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims. - Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures. - Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary. - Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary. - Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities. - Attend and participate in regional FWA Task Force and other state or federal meetings. - Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies. - Ensure regulatory reporting is developed, accurate, and submitted timely. - Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA. - Develop and conduct internal FWA related training. - Collaborate with government agencies during audits, investigations and Requests for Information (RFI). - Present and discuss case findings and recommendations in case review meetings with department and company management. - Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board. - Coordinate and manage the production of investigative materials in support of settlement negotiations. Qualifications - Minimum of 4 years of experience conducting complex healthcare fraud investigations required. - Significant experience in facilitating audit activities across specialized teams required. - Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required. - Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required. - Experience in navigating case management, claims and OSINT platforms preferred. - Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required. - Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required. Requirements - Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse is required. - Ability to gain a thorough understanding of PacificSource compliance initiatives. - Respond timely to regulatory inquiries. - Maintain sufficient reference materials to adequately research compliance issues. - Ability to organize large complex investigative audits that involve working with multi-functional teams under strict deadlines. - Ability to communicate effectively with all levels of the organization, federal and state agencies, providers, and members, both verbally and in writing. - Working knowledge of legal and medical terminology. - Ability to read, interpret, and apply the complex language and ideas found in provider contracts, case law, criminal and civil statutes. - Ability to work under time pressures, and remain professional in emotionally charged situations. - Computer proficiency in a Windows environment, including Microsoft Office Suite. Benefits - Base Range: $65,296.83 - $111,004.62 - Compensation is determined based on factors such as qualifications, experience, education, and internal equity. Company Description PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Role Description This position is accountable for the Provider Network department’s core operational, data, and systems functions. This role will oversee Provider Network divisions including Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability. This position leads both department-specific and cross departmental planning and execution efforts, to maintain high levels of performance in enterprise level and Provider Network level key performance indicators. This position is responsible for all lines of business (Medicaid, Medicare, Commercial) and leads in strong alignment with the company’s strategic plan, vision, and values. - Guide strategic initiatives for the Provider Network Operations division, including network setup and maintenance, provider data integrity, provider education and service, contract implementation performance, provider-related claims, provider setup and audits, corrective action plan assessment and closure, and provider directory accuracy improvements. - Collaborate with Provider Reimbursement Insights and Analytics Team to ensure success in meeting objectives. Develop, direct and execute efforts to meet Credentialing division objectives, ensuring compliance and operational excellence. - Develop and execute strategies for provider education and relationship management to enhance provider collaboration, engagement, and satisfaction within the Provider Relations Team. - Lead initiatives to ensure seamless integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems. - Fostering partnerships with software vendors and internal stakeholders to optimize the interoperability of tools and streamline network operations. - Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions to enhance system compatibility. - Ensure integrated systems support compliance with state, federal, and NCQA standards, as well as organizational policies. - Develop automated workflows and processes that ensure accurate synchronization of data across all platforms and departments. - Strengthen relationship management frameworks to ensure consistent communication and support for provider partners. - Actively participate in department strategic planning, execution, resource allocation, and performance monitoring. - Oversee and guide provider collaborative efforts in coordination with other key departments and leaders. - Guide division functional leaders to develop business plans that ensure successful initiatives have a positive impact on the member, provider partners and PacificSource. - Design and deliver provider education programs to ensure understanding of network policies, reimbursement processes, and regulatory requirements. - Regularly assess provider feedback and implement enhancements to address pain points and improve relationships. - In partnership with Operations, IT, Health Services, Analytics, Finance and other departments, collaborate to maximize the alignment and value of various initiatives. - Oversee the planning of annual IT work plans, initiative work plans, financial budgets, and resource needs for the role of supervisory departments. - Develop and implement coaching and training programs with division leaders to foster team growth. - Responsible for hiring, staff development, coaching, and performance reviews. - Responsible for overall employee engagement enhancement within Provider Network to include implementation of education/programs and other desired cultural enhancements. - Oversee division budgets and spending. Monitor spending versus the planned budget throughout the year and assess appropriate corrective actions as needed. - Actively participate in Manager/Supervisor meetings, PRISM walks, internal committees and other key department activities and disseminate information as appropriate. Qualifications - Minimum of 8 years in healthcare operations required. - Management experience required. - Must have expertise in provider reimbursement methodologies, provider relations, data management and compliance. - Experience developing, communicating, and executing strategy in a matrixed organizational structure. Requirements - Bachelor’s degree in business, health care administration, finance, or related field required. - Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered. Benefits - Base Range: $108,468.62 - $184,396.64 Company Description PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Role Description Responsible for successful execution, coordination and support of PacificSource’s clinical/quality improvement initiatives, across all lines of business. Key areas of focus include oversight and management of provider clinical engagement and performance on patient populations. This is done through collaborating with targeted provider groups to guide and develop practice specific strategies designed to optimize clinical quality outcomes, risk assessment performance, and clinical outcomes via care management and cost containment. Work directly with internal PacificSource departments to build/strengthen relationships with strategic provider partners; ensure effective education, analyze and generate specific clinical reports and proactively identify clinical improvement opportunities that support PacificSource’s strategic goals. Assist with the development and execution of region specific strategies and practice coaching. Essential Responsibilities: - Assist with the development and execution of enterprise wide provider campaigns focused on improving clinically oriented improvement and outcomes (HEDIS, CAHPS/HOS scores and other identified quality improvement measures). - Provide ongoing training, coaching and high-touch support to network providers and clinic staff toward the development and implementation of improvement initiatives (clinical quality, member experience, clinical workflows, and documentation/coding practices) within their own practices. - Establish credible, consultative relationships with network physicians and clinic staff as a subject matter expert on clinical quality improvement measures and risk assessment including the technical reporting and documentation requirements NCQA (HEDIS and CAHPS), risk adjustment. - Collaborate with multiple departments (Risk Assessment, Care Management, Utilization Management, Pharmacy, and Medical Directors) to develop and deploy aligned quality performance programs to drive member care outcomes and improved provider satisfaction. - Maintain a detailed understanding of all shared data elements (clinical outcomes, ICD-10 coding, and documentation) and the systems necessary to support actionable interventions. - Support internal initiatives to improve the collection and reporting of supplemental HEDIS data as related to provider populations. - Evaluate quality programs, initiatives and interventions utilizing multiple data sources to determine the effectiveness of activities and make recommendations to improve outcomes for CMS Stars, NCQA, QIM (HEDIS, CAHPS). - Lead internal/external cross functional teams with regional focus to develop and deploy annual improvement plans with performance metrics, monitor risk, deploy mitigation strategies and elevate to joint operating committees as needed. - Support all clinical and quality dyads with provider payer partnerships to optimize engagement, drive performance and improve provider/member experience in service to growth strategy. Supporting Responsibilities: - Represent Quality Improvement internal committees and workgroups. - Meet department and company performance and attendance expectations. - Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. - Perform other duties as assigned. Qualifications - Minimum of 5 years of experience in the healthcare industry required. Health care clinic experience preferred. - Operational leadership or clinic manager preferred and/or other Population Health Program implementation experience preferred. Requirements - Bachelor degree in healthcare administration or similar field is required or equivalent work experience. - Master’s degree and/or Clinical license preferred. Knowledge - Knowledge/experience with quality improvement initiatives in the clinic setting including clinical quality outcomes and patient experience. - Knowledge of national and state quality measures such as CMS Stars, NCQA, HEDIS, CAHPS/HOS required. - Strong computer skills using Word, Excel, and PowerPoint. - Experience with medical billing, claims processing systems, data analytics, and health care information strongly preferred. - Knowledge and experience implementing continuous improvement efforts or LEAN concepts strongly preferred. - Must have strong analytical, influencing, and problem solving skills. - Understanding of quality initiatives, evidence based medicine and care coordination required. - Demonstrated ability to effectively communicate with all levels of a staff and management including executive leaders. - Proven ability to learn new healthcare information systems and work with multiple business systems. - Must be self-motivated, organized, and detailed oriented. Competencies - Building Trust - Building Customer Loyalty - Facilitating Change - Driving for Results - Building Strategic Work Relationships - Leveraging Diversity - Decision Making - Building a Successful Team - Aligning Performance for Success - Continuous Improvement Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 25-50% of the time. Skills - Accountability - Collaboration - Communication (written/verbal) - Flexibility - Listening (active) - Organizational skills/Planning and Organization - Problem Solving - Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $72,443.87 - $126,776.77 Our Values - We are committed to doing the right thing. - We are one team working toward a common goal. - We are each responsible for customer service. - We practice open communication at all levels of the company to foster individual, team and company growth. - We actively participate in efforts to improve our many communities-internally and externally. - We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. - We encourage creativity, innovation, and the pursuit of excellence. Physical Requirements - Stoop and bend. - Sit and/or stand for extended periods of time while performing core job functions. - Repetitive motions to include typing, sorting and filing. - Light lifting and carrying of files and business materials. - Ability to read and comprehend both written and spoken English. - Communicate clearly and effectively. Disclaimer This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

• Facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation • Collect and assess patient information pertinent to patient’s history, condition, and functional abilities • Develop a comprehensive, individualized care management plan • Link clients with appropriate providers and resources throughout the continuum of health and human services and care settings • Ensure that the care provided is safe, effective, client-centered, timely, efficient, and equitable • Interact with other PacificSource personnel to assure quality customer service is provided • Act as an internal resource by answering questions requiring medical or contract interpretation

• Assist in the accurate and comprehensive data submission to regulatory entities • Collaborate and coordinate with internal and external partners to minimize submission and response errors • Accumulate and report out on pertinent data sets • Develop and improve processes related to risk adjustment and quality improvement • Maintain required documentation and ensure compliance to all applicable laws, guidance, and regulations • Assume lead role on specified projects • Provide mentorship to less experienced team members • Influence decision making by leadership and provide recommendations regarding potential improvements to risk adjustment processes