Role Description You are a detail-oriented fraud and financial investigations professional with experience in AML/BSA compliance, fraud detection, and complex case management. You excel at analyzing suspicious activity, gathering and evaluating evidence, and partnering with internal teams, law enforcement, and financial institutions to mitigate risk and protect organizational assets. With strong investigative, analytical, and communication skills, you serve as a trusted subject matter expert who supports compliance efforts, mentors team members, and drives effective fraud prevention and loss mitigation strategies. - Utilizes knowledge of credit union systems, processes, and contacts as resources for conducting investigations. - Develops a plan of action and gathers, analyzes, and compiles evidence for multiple case assignments. - Prepares case documentation and writes a complete final summary report of investigation. - Investigate and respond to check fraud claims as received by members and/or other financial institutions. - Investigate suspicious activity cases generated by the internal automated AML/BSA monitoring system or Unusual Activity Referrals reported by branch personnel and other lines of business. - Review cases assigned for closure to ensure Verafin case has proper coding, and all steps are taken prior to closing account in DSUI. - Assesses internal controls and procedures associated with assigned cases, identifying control breakdowns and makes recommendations to prevent future losses. - Assists with determining new procedures to prevent, detect, and investigate fraudulent activity. - Reviews fraud data to ensure accuracy for reporting and audit purposes. - Assist with computer crime investigations and investigate breaches of information security policies as requested. - Prepares recommendations as to whether a member’s transactional activity is fraudulent and thereby requiring a BSA UAR referral. - Reviews individuals’ and entities’ accounts reported in a police report utilizing different management systems to determine if other suspicious activity noted in the accounts should be reported. - Prepares police report and/or BSA UAR referral if necessary. - Performs red flag alert reviews on account activity for submitted fraud closures. - Files supplemental police report if additional suspicious activity is identified and works with BSA SAR Investigator on continued 90-day fraud referrals. - Assist with auditing Investigator I BSA narratives prior to submitting to BSA department. - Maintains current information on various systems as well as required files and documentation. - Ensures records are complete and available for review and audit as needed. - Complies with regulatory requirements, security, and applicable policies and identifies control and procedural issues. - Serves as resource to branches/departments inquiries related to financial investigations questions. - Assists with the timely completion and investigation of assigned 314(b) requests. - Completes annual BSA/AML/OFAC training requirements and keeps current with Money Laundering and Terrorist Financing trends. - Provides support, guidance, and training of new staff and serves as the quality control reviewer for alerts, cases, and BSA UAR referrals. - Assists in collecting documentation for examiners, auditors, law enforcement, and governmental agencies regarding fraudulent activity and BSA/AML monitoring records. - Participates in moderate to complex project initiatives as the primary subject matter expert. - Maintain a thorough understanding of state and federal laws and regulations related to credit union compliance including bank secrecy and anti-money laundering laws appropriate to the position. - Assists and identifies other investigative efforts within the department, including creating and working moderately complex cases. - Understand CTR filing requirements and be able to answer basic questions. - Assists with the training of new staff and acts as a resource for all team members regarding a variety of loss prevention and fraud scenarios. - Assists in development and facilitation of fraud prevention and awareness for all branch and HQ staff as applicable. - Maintain accurate tracking of work performed, which will be used in department performance measurements. - Prepare police reports for all losses over the established thresholds or established behaviors outlined in department procedures. - Work with law enforcement as required, providing updates or additional information as needed. - Responds to law enforcement agencies and financial institutions requesting documentation and/or images to support investigations involving credit union losses. - Perform other duties as assigned. Qualifications - Bachelor’s Degree or combination of experience and education required. - 5+ years financial institution or law enforcement experience and Fraud, AML, or card fraud experience required. Benefits - Market-competitive and internally equitable total rewards compensation package. - Programs designed to attract, motivate, and retain employees. - Comprehensive compensation package. - Well-being and work-life balance. - Career development and growth. - Rewards and recognition. - Commitment to Diversity, Equity and Inclusion.

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 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 The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. - Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations. - Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items. - Manage strategic investigative plan and drive investigative outcome for the team. - Ensure quality outcomes for investigative team through auditing and oversight. - Prioritize, track, and report status of investigations. - Report identified corporate financial impact issues. - Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions. - Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines. - Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach. - Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling. - Coordinate and conduct on-site and desk audits of medical record reviews and claim audits. - Manage and decision claims pended for investigative purposes. - Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types. - Prepare and conduct in-depth complex interviews relevant to investigative plan. - Execute and manage provider formal corrective action plans. - Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development. - Participate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigation. - Present, support, and defend investigative research to seek approval for formal corrective actions. - Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention. - SME in the designated market and ability to apply external intelligence to their analysis and case development. - Develop and present internal and external formal presentations, as needed. - Attend fraud, waste, and abuse training/conferences, as needed. - Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies. - Manage and maintain sensitive confidential investigative information. - Maintain compliance with state and federal laws and regulations and contracts. - Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan. - Assist in Federal and State regulatory audits, as needed. - Perform any other job-related instructions, as requested. Qualifications - Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required. - Master’s Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred. - Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required. Requirements - Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint. - Effective listening and critical thinking skills and the ability to identify gaps in logic. - Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties. - Excellent problem solving and decision making skills with attention to details. - Background in research and drawing conclusions. - Ability to perform intermediate data analysis and to articulate understanding of findings. - Ability to work under limited supervision with moderate latitude for initiative and independent judgment. - Ability to manage demanding investigative case load. - Ability to develop, prioritize and accomplish goals. - Self-motivated, self-directed. - Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences. - Presentation experience, beneficial. - Knowledge of Medicaid, Medicare, healthcare rules preferred. - Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred. - Complex project management skills preferred. - Display leadership qualities. Licensure and Certification - One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE). - Certified Professional Coder (CPC) is preferred. - NHCAA or other fraud and abuse investigation training is preferred. Working Conditions - General office environment; may be required to sit or stand for extended periods of time. - Occasional travel (up to 10%) to attend meetings, training, and conferences may be required. Compensation Range $72,200.00 - $115,500.00. CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type Salary Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.