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, including demonstrated ability to independently own complex, recurring deliverables under review. - 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, including the ability to build, follow, and improve complex, multi-schedule workpapers with accuracy. - Demonstrated ability to work independently from established workpapers and processes and to apply strong critical thinking and problem-solving to complex, technical, and unfamiliar subject matter. - Familiarity with statutory (SAP) accounting, income tax provision (ASC 740 / SSAP 101), and multi-jurisdiction tax compliance concepts, with the ability to deepen specialized knowledge under expert guidance. - Comprehensive understanding of GAAP and general accounting and business practices; proficiency in ERP/accounting software (Workday experience a plus). - Ability to define and prioritize problems and to manage a workload spanning multiple concurrent regulatory and tax deadlines with limited direct supervision. - Strong organizational skills, attention to detail, and clear written and verbal communication; a coachable team player comfortable being supported by subject-matter experts. Benefits - Base Range: $74,601.93 - $126,822.77 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 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 research 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 - Compensation range: $65,296.83 - $111,004.62. - Wage range reflects the full range for this position; actual compensation will be determined based on 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 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. - Bachelor degree in healthcare administration or similar field is required or equivalent work experience. Master’s degree and/or Clinical license preferred. Requirements - 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 detail oriented. Benefits - Base Range: $72,443.87 - $126,776.77 Company Description We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: - 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.

Role Description The Senior Risk Adjustment (RA) Analyst assists in the accurate and comprehensive data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable populations. This position leverages available tools and knowledge of the applicable risk models to optimize data submission as it pertains to Hierarchical Condition Categories (HCCs), HEDIS® and Quality performance as well as other data within a given system. The Senior RA Analyst will collaborate and coordinate with internal and external partners to minimize submission and response errors, provide thorough oversight of vendor partners, 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. Projects are completed with cross-functional teams of peers and business partners. This includes interaction with provider partners with the intent of informing them on performance and educating on best practices in risk adjustment. The Senior RA Analyst will provide mentorship to less experienced team members. In addition, this position influences decision making by leadership and provides recommendations regarding potential improvements to risk adjustment processes and outcomes. Qualifications - Five years’ experience in data analytics or software development required. - At least three years’ experience in Health Plan required. - In-depth risk adjustment and/or HEDIS® experience required. - Expertise in Microsoft Excel and SAS/SQL is required. - Experience in leading projects and project teams required. - Familiarity with Medicaid risk adjustment and CMS 5-Star required. - Familiarity with Risk Adjustment Documentation, Coding practices and NCQA quality metric experience preferred. - Equivalent work and education experience will be considered. Requirements - Recommend and guide process improvements that will optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden. - Identify, analyze, interpret and communicate risk adjustment trends to be consumed by provider partners and related entities. - Responsible for maintenance of existing reports, development of new reports to help ensure company goals are met, as well as other ad hoc requests as needed. - Develop and maintain reporting capabilities to measure and forecast risk scores & quality metrics, monitor suspecting model performance, and identify areas of improvement. - Maximize risk adjustment revenue and quality bonus payments by driving data integration and analytics to properly capture and improve the health status of PacificSource members. - Validate data integrity and collaborate with technical teams to improve data pipelines and business logic for identified areas of opportunity. - Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment and quality data submission. - Develop and maintain data sets leveraging internal data, response data from regulatory entities, and ancillary data sources to be consumed across the enterprise. - Demonstrate mastery in running all applicable risk models including the various CMS models for Medicare Advantage members, the HHS model for Commercial ACA members, and others as needed. - Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy. - Assist with all pertinent audits, including RADV, through preparation activities and documentation. - Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings. - Develop, maintain, and report out on actionable metrics related to risk adjustment and HEDIS® to incorporate quality/health outcome metrics where applicable. - Prepare new and review existing specifications, project plans, and other internal procedural documents. - Provide support as needed for projecting annual receivable amounts, preparing projections related to pricing efforts, and predicting cost utilization as it relates to risk adjustment. - Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes. - Provide mentorship, leadership, and training to less experienced risk adjustment analysts. Benefits - Base Range: $74,601.93 - $126,822.77 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 The Corporate Communications Specialist helps manage communications across PacificSource’s core channels, with primary responsibility for the company intranet, newsletters, and recurring content programs. This role partners with teams across the organization to plan, develop, and publish content that is timely, accessible, and aligned with strategic priorities. - Produce storytelling that highlights employee contributions, member experiences, and community impact. - Manage distribution of stories across internal channels, while supporting management of our owned external platforms as needed (e.g. website and newsletters). - Develop content that supports strategic priorities in clear, accessible language. - Manage internal newsletter production from planning through distribution. - Coordinate content calendars and ensure alignment across communication moments and audiences. - Support development of internal PowerPoint materials with clear structure, formatting, and visual consistency. - Own day-to-day management of the company intranet, ensuring content is current, organized, and easy to navigate. - Partner with stakeholders to source, prioritize, and refine intranet content. - Format and present intranet content using light design to improve readability and engagement. - Monitor channel performance and engagement trends to inform improvements. - Recommend enhancements to content structure, timing, and delivery. - Maintain consistency in tone, voice, and messaging with the corporate brand identity to align with and reinforce the organization's brand and reputation. Qualifications - A minimum of 4 years of experience in related communications or marketing role required. - Experience monitoring public perception and addressing issues proactively, along with a strong understanding of media relations and proactive storytelling, is strongly preferred. - Healthcare experience preferred. - Bachelor’s degree in communications, marketing, advertising, journalism, business or related field preferred. - High school diploma or equivalent required. - Excellent written and verbal communication skills required, with a proven ability to craft compelling content for various channels. - Ability to collaborate effectively with internal teams and maintain consistency in brand messaging. - Understanding of the core principles of strategic communications, marketing, design, Microsoft Word and PowerPoint, marketing email, and survey software. - Sound understanding of the principles of marketing and current best practices for both business to business and business to consumer marketing. - Demonstration of strategic thinking, attention to detail, and the ability to adapt messaging for different audiences and platforms. - Awareness of local community and value of potential community partners. - Highly organized with ability to manage multiple projects concurrently, often to tight deadlines. - Willingness to jump in on an array of projects as requested; eager to learn new skills. - Flexible and adaptable, able to react quickly to changing requirements and new challenges. Requirements - Build and maintain professional, service-oriented relationships with customers throughout the organization. - Build knowledge of company’s benefits, compliance regulations, policies and procedures that relate to communications. - 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. Benefits - Compensation range: $56,779.86 - $96,525.75. - The wage range provided reflects the full range for this position. - Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 10% of the time. 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 Responsible for leading provider credentialing, recredentialing, and provider data management operations across PacificSource. Ensures compliance with regulatory and accreditation requirements (e.g., NCQA), maintains provider data integrity, and drives operational excellence across credentialing and provider data functions. Partner cross-functionally to support organizational goals, improve processes, and enhance data quality and reporting with a strong focus on data optimization, extraction, and taxonomy for current and future business needs across all lines of business. Demonstrate effective leadership by developing teamwork and team support, managing change and encouraging innovation, building collaborative relationships, encouraging involvement and initiative, and developing increased vision and commitment to goals. Essential Responsibilities - Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. - Provide feedback, including regular one-on-ones and performance evaluations, for direct reports. - Responsible for positive departmental culture as it relates to following and modelling company values and identifying and pursuing improvements based on employee engagement survey results. - Manage daily operational performance and collaboration, as well as highlight team accomplishments. - Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed. - Develop and implement adequate programs and processes ensuring complete programs that meets or exceeds requirements. - Lead and manage all credentialing and recredentialing operations, ensuring compliance with NCQA, regulatory, and accreditation standards; oversee credentialing committee workflows and provider approval processes. - Direct provider data management operations, including provider setup, data integrity, database maintenance, provider directory accuracy, and processes impacting claims and encounter data. - Oversee internal audit activities, compliance findings, corrective action plans, and reporting requirements to ensure operational and regulatory compliance. - Design, implement, and continuously improve systems, processes, and workflows to enhance efficiency, data accuracy, and audit readiness across credentialing and provider data functions. - Advance data strategy initiatives, including data optimization, taxonomy, extraction, and reporting capabilities to support organizational and operational needs. - Provide oversight of site surveys and medical record review processes, including associated travel, documentation, and compliance requirements. - Maintain and manage delegated credentialing arrangements and support accreditation efforts, including ongoing readiness for NCQA and other regulatory reviews. - Partner cross-functionally with Provider Network Contracting, Provider Relations, and other departments to align processes, improve service delivery, and support business objectives. - Collaborate with internal and external stakeholders, including providers and vendor partners, to ensure accurate and effective credentialing and provider data operations. - Identify, evaluate, and implement process improvements and technology solutions, including system enhancements and vendor tools (e.g., Cactus, Facets), to optimize performance and scalability. - Monitor operational performance through key metrics, dashboards, and continuous improvement practices (e.g., huddles, lean methodologies) to identify trends and drive outcomes. - Evaluate provider network data and reporting to support decision-making, including network assessments and business development needs. - Lead, coach, and develop staff, including hiring, performance management, employee engagement, and ongoing professional development. - Ensure compliance with HIPAA and confidentiality requirements in all aspects of credentialing and provider data management activities. - Represent the function in leadership meetings, committees, and organizational initiatives; communicate key updates and ensure alignment across teams. Supporting Responsibilities - 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 healthcare or healthcare operations experience required. - Experience in credentialing, provider data management, or working within regulatory or accreditation environments (e.g., NCQA) is required. - Familiarity managing delegated credentialing relationships and using provider data systems such as Symplr or Facets. - Prior supervisory experience is strongly preferred. - Bachelor’s degree 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. Knowledge - Advanced knowledge of provider reimbursement methodologies. - Knowledge of healthcare delivery, NCQA, and HIPAA are essential. - Ability to gain knowledge of PacificSource policies and procedures. - Foster attitude of cooperation and professionalism with external and internal contacts. - Ability to identify problems and work toward problem resolution independently, seeking guidance as needed. - Attention to detail; ability to handle multiple tasks and prioritize effectively. - Must show initiative in approaching projects and day-to-day work. - Attendance at meetings beyond regular business hours is required. - Must be proficient in Word, Excel, Databases, and credentialing software programs. Competencies - Building Trust - Building a Successful Team - Aligning Performance for Success - Building Partnerships - Customer Focus - Continuous Improvement - Decision Making - Facilitating Change - Leveraging Diversity - Driving for Results Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 15% of the time. Skills - Accountable leadership - Collaboration - Data-driven & Analytical - Delegation - Effective communication - Listening (active) - Situational Leadership - Strategic Thinking 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: $90,052.16 - $157,591.26 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.

Role Description The Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives. - Leads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals. - Oversees a comprehensive suite of pre- and post-payment programs—including claims editing, audits, subrogation, readmission reviews, and coordination of benefits. - Continuously refines approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes. - Manages external vendors supporting audits, analytics, and fraud detection. - Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations. - Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes. - Directs Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams. - Leverages predictive analytics and rules engines to identify suspicious billing patterns. - Ensures compliance with ICD-10, CPT/HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement. - Serves as a subject matter expert on complex coding issues and documentation standards. - Integrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications. - Maintains compliance with CMS, Medicaid, ACA, and state-specific regulations. - Leads audit responses and represents the organization in national forums. - Champions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection. - Pilots emerging technologies and integrates them into core operations. - Collaborates with IT and analytics teams to enhance data infrastructure and reporting capabilities. - Partners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization. - Translates complex technical concepts into actionable insights for diverse stakeholders. - Responsible for oversight, management, development, implementation, and communication of department programs. - Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. - Develop annual department budgets and monitor spending versus the planned budget throughout the year. - Coordinate business activities by maintaining collaborative partnerships with key departments. - Responsible for process improvement and working with other departments to improve interdepartmental processes. - Actively participate as a key team member in Manager/Supervisor meetings. - Actively participate in various strategic and internal committees. Qualifications - A minimum of 5 years of progressive experience in healthcare operations. - Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required. - Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration. - Bachelor’s degree required. Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience will also be considered. - Preferred area of focus: Healthcare Operations, Statistics, or a related field. Requirements - Proven track record of leading operational initiatives from concept through execution. - Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes. - Comprehensive understanding of federal and state Medicaid payment regulations. - Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions. Benefits - Base Range: $90,052.16 - $157,591.26 Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 10% of the time. Skills - Accountable leadership - Collaboration - Data-driven & Analytical - Delegation - Effective communication - Listening (active) - Situational Leadership - Strategic Thinking 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.

Role Description Supervise and provide guidance to Customer Service Representatives regarding department policies, procedures, and workflow. Responsible for hiring, mentoring, coaching and evaluating team members’ performance. Demonstrate effective leadership to improve individual performance and develop teamwork and team support. Manage change and encourage collaborative relationships, involvement and initiative. - Provide supervision, coaching, training, support, evaluation and leadership to assigned staff. - Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. - Provide feedback, including regular one-on-ones and performance evaluations, for direct reports. - Assist with process improvement and work with other departments to improve interdepartmental processes. - Utilize lean methodologies for continuous improvement. - Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities. - Monitor, evaluate and report service performance for the department and determine staffing needs related to day-to-day performance goals. - Investigate and settle issues not resolvable by customer service representatives. - Relay information for dispute resolution to appropriate departments and personnel. - Assist with answering inquiries received by phone, mail, e-mail or in person, providing exceptional service. - Assist in appeal research and resolution. - Coordinate business activities by maintaining collaborative partnerships with key departments. - Actively participate as a key team member in department meetings. - Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy. - Serve as back-up to the Customer Service Manager as needed. Qualifications - Two years medical insurance or other healthcare related field preferred. - Prior customer service/call center experience preferred. - Claims processing preferred. - Experience in leadership preferred. - High School Diploma or equivalent required. Requirements - Computer Skills, Typing and 10-key required. - Medical terminology, CPT & ICD-9 coding preferred. - Microsoft Word/Excel preferred. Benefits - Base Range: $50,830.78 - $81,329.23 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 The Member Support Specialist will work as an integral part of the case management team to serve as a resource to members. The Specialist will work telephonically and in person to support members with complex psycho-social issues which create barriers to adherence with medical regimens and achievement of optimal health outcomes. Examples may include activities such as assisting with arranging transportation, linking patients with community resources, etc. Will assist with program development, and build effective member and provider relationships. - In coordination with the member’s case manager, develop and implement goals and/or plans tailored to assist members in navigating the complexities of the healthcare system. - Educate members on understanding and working within the parameters of their benefit structure. - Utilize motivational interviewing and patient-engagement techniques to support members in achieving optimal health outcomes by effectively utilizing their benefits. - Identify community resources and make referrals to members as appropriate. - Serve as liaison between members and providers/agencies. - Identify members for coordination and case management services through a variety of methods, including claims data and reports. - Screen requests to identify appropriate referrals to case management from multiple internal and external sources. - Work collaboratively with the case management team to help facilitate case management process. Participate in case management/care coordination meetings. - Ensure compliance with applicable state and federal regulations and guidelines in day-to-day activities, including maintaining HIPAA standards and confidentiality of protected health information. Ensure accurate and timely documentation. - Assist members with referrals, scheduling appointments and ensuring transportation to medical appointments is available. - Assist members with non-clinical needs for transitions and different phases of care. - Manage mailing lists and outgoing mailings. Supporting Responsibilities - Assist with the development of departmental procedures, reports and projects. - Assist care management to meet quality measures as outlined by government regulations. - Enter and collate data: prepare reports as assigned. - Participate in team, department, company, and community-related committees as requested. - Make presentations to small groups. Actively participates in quality improvement initiatives. - Meet department and company performance and attendance expectations. - Perform other duties as assigned. Work Experience - A minimum of three years of experience in community services or healthcare agencies focused on coordination services required. - Experience in health insurance and delivering group presentations preferred. Education, Certificates, Licenses - High school diploma or equivalent required. Knowledge - Medical terminology. - Proficient in Microsoft Office, including Word, Excel, PowerPoint, Medical management software (e.g CaseTrakker Dynamo). - Excellent verbal and written communication skills and is able to work independently as well as to work effectively on a team. - Good working knowledge of how to access community resources and healthcare system. Competencies - Building Customer Loyalty - Building Strategic Work Relationships - Contributing to Team Success - Planning and Organizing - Continuous Improvement - Adaptability - Building Trust - Work Standards Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 20% 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: $35,542.81 - $56,868.50 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.