PacificSource Health Plans

Investigator

• 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.

Senior Investigator

Program Manager

• 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.

Fraud, Waste, and Abuse Program Manager

• 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
• 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

• 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.

Network Operations

• Accountable for the Provider Network department’s core operational, data, and systems functions.
• Oversee Provider Network divisions including Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability.
• Guide strategic initiatives for the Provider Network Operations division.
• Collaborate with Provider Reimbursement Insights and Analytics Team.
• Develop, direct and execute efforts to meet Credentialing division objectives.
• Lead initiatives for seamless integration of provider network platforms.
• Collaborate with IT teams and operational leaders.
• Develop automated workflows and processes.
• Monitor division budgets and spending.
• Provide feedback, coaching, and development for direct reports.

Director, Provider Network Operations

Manager

• Oversee daily UM operations for inpatient services including clinical review, authorization, and concurrent review processes
• Ensure timely level of care determinations alignment with clinical guidelines and regulatory requirements
• Collaborate with hospital case managers, providers, and interdisciplinary teams to facilitate safe and cost-effective discharge plans for patients
• Monitor and track and analyze inpatient length of stay metrics, readmissions, key performance indicators (KPIs), and turnaround times
• Oversee utilization review for skilled nursing facilities, home health, long-term acute care, and other post-acute settings
• Establish effective transitions of care with post-acute providers to reduce preventable readmissions and promote optimal member outcomes
• Use evidence-based protocols to ensure medical necessity for continued stays
• Provide leadership and direction for Dual-Eligible Special Needs Plan (DSNP) utilization management
• Ensure compliance with state and federal regulations and DSNP contractual obligations
• Develop, implement, and regularly update policies and procedures to ensure compliance and best practices in utilization management
• Prepare for and manage internal and external audits pertaining to UM and DSNP activities
• Work closely with the UM Director to facilitate the development and implementation of new programs
• Directly supervise the UM inpatient team, along with staff focused on post-acute and DSNP reviews
• Recruit, train, and mentor clinical reviewers, nurses, coordinators, and other UM personnel
• Conduct performance evaluations, set goals, and foster professional development

Manager, Inpatient and Post Acute Services

Human Resources

• Lead a team of Human Resources Business Partners (HRBP) and HR Specialists who serve as strategic partners to business leaders.
• Ensure HR initiatives align with organizational and strategic goals, foster a positive employee experience, and drive talent strategies that support growth and performance.
• Provide guidance on workforce planning, employee relations, organizational development, and compliance while coaching HRBPs to deliver high-impact solutions.
• Oversee and lead the HR Business Partner (HRBP) and HR Specialist teams to ensure HR strategies and daily work align with business objectives, providing strategic oversight and management of department programs, including the development, implementation, and communication of initiatives.
• Collaborate with organizational leaders to create actionable plans that strengthen workforce planning, organizational design, employee engagement, and culture strategies while maintaining strong partnerships through comprehensive HR advice on business matters.
• Advise and coach leaders on talent development, retention strategies, performance management, employee relations, policy interpretation, conflict resolution, and compliance with legal and contractual requirements; support succession planning and leadership development programs.
• Champion cultural initiatives, foster open communication, reinforce company values, and influence critical talent decisions such as hiring, promotions, and internal mobility to ensure alignment with organizational goals and retention of top performers.
• Drive initiatives to facilitate 9-box talent discussions with leadership, collaborate with and advise leaders on strategies for developing and retaining high-potential employees, and oversee timely completion performance review processes as well as annual merit incentive programs.
• Collect, analyze, and synthesize quantitative and qualitative data to identify trends, develop actionable recommendations, and recognize patterns to inform decision-making and process improvements for programs such as onboarding effectiveness, exit interviews, 9 box process, performance reviews and more.
• Manage complex HR projects and initiatives, ensuring successful development, implementation, and rollout to support organizational objectives, utilizing lean methodologies and drive continuous improvement.
• Provide expert guidance on complex employee relations issues, ensure adherence to federal, state, and local employment regulations, and supervise workplace investigations and dispute resolution processes.
• Responsible for hiring, staff development, coaching, conducting performance reviews, corrective actions, and terminations; deliver feedback through regular one-on-ones and performance evaluations, and work with other departments to improve interdepartmental processes.
• Assist in developing annual budget. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed. Coordinate business activities by maintaining collaborative partnerships with key departments.

Manager, Human Resources

Clinician

• Clinician Care Managers 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 in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services
• Based on the needs and values of the client, and in collaboration with all service providers, the clinician links 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
• Clinicians have direct communication among the client, the payer, the primary care provider, and other service delivery professionals
• 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 that are referred from other departments, as well as physicians and providers of medical services and supplies
• Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients
• Practice and model effective communication skills: both written and verbal
• Utilize and promote use of evidence-based tools
• Utilize lean methodologies for continuous improvement

Care Management Clinician

• 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

• Lead a team of Human Resources Business Partners (HRBP) and HR Specialists who serve as strategic partners to business leaders
• Ensure HR initiatives align with organizational and strategic goals
• Foster a positive employee experience, and drive talent strategies that support growth and performance
• Provide guidance on workforce planning, employee relations, organizational development, and compliance while coaching HRBPs to deliver high-impact solutions
• Ensure compliance with all regulations and maintain confidentiality
• Oversee and lead the HR Business Partner (HRBP) and HR Specialist teams to ensure HR strategies and daily work align with business objectives
• Collaborate with organizational leaders to create actionable plans that strengthen workforce planning, organizational design, employee engagement, and culture strategies
• Advise and coach leaders on talent development, retention strategies, performance management, employee relations, policy interpretation, conflict resolution, and compliance with legal and contractual requirements
• Champion cultural initiatives, foster open communication, reinforce company values, and influence critical talent decisions
• Drive initiatives to facilitate 9-box talent discussions with leadership
• Collect, analyze, and synthesize quantitative and qualitative data to identify trends, develop actionable recommendations, and recognize patterns to inform decision-making

Risk

• 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

Senior Risk Adjustment Analyst

• Guide strategic initiatives for the Provider Network Operations division.
• Collaborate with Provider Reimbursement Insights and Analytics Team.
• Develop, direct and execute efforts to meet Credentialing division objectives.
• Lead initiatives to enhance provider collaboration, engagement, and satisfaction.
• Collaborate with IT teams to identify interoperability gaps.
• Ensure integrated systems support compliance with state, federal, and NCQA standards.
• Develop automated workflows and processes for data synchronization.
• Strengthen relationship management frameworks for consistent communication.
• Actively participate in department strategic planning and execution.
• Oversee provider collaborative efforts in coordination with key departments.
• Guide division functional leaders in developing successful business plans.
• Design and deliver provider education programs.
• Regularly assess provider feedback for relationship improvements.

• Guide strategic initiatives for the Provider Network Operations division
• Collaborate with teams to ensure success in meeting objectives
• Develop, direct and execute efforts to meet Credentialing division objectives
• Lead initiatives to ensure seamless integration and ongoing operational effectiveness of provider network platforms
• Foster partnerships with software vendors and internal stakeholders
• Ensure integrated systems support compliance with state, federal, and NCQA standards
• Oversee division budgets and spending
• Monitor spending versus the planned budget throughout the year

Compliance

• Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare, and Medicaid lines of business
• Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A staff for purposes of monitoring and ensuring compliant operations
• Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the G&A Department
• Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance
• In partnership with Compliance staff and G&A leadership, develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations
• Serve as an inter-departmental liaison for compliance and FWA activities
• Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal an internal business rules and regulations
• Be fully informed and ensure compliant processes are in place on all G&A business operations
• Maintain a current working knowledge of all applicable Medicare, and Medicaid rules and regulations
• Conduct frequent monitoring activities of all G&A business operations, publish results and report out to G&A Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable
• Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors in a timely, professional and accurate manner

Regulatory and Reporting Specialist

• Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare and Medicaid lines of business
• Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A staff for purposes of monitoring and ensuring compliant operations
• Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the G&A Department
• Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance
• Develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations
• Serve as an inter-departmental liaison for compliance and FWA activities
• Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal and internal business rules and regulations
• Be fully informed and ensure compliant processes are in place on all G&A business operations
• Conduct frequent monitoring activities of all G&A business operations, publish results and report out to G&A Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable
• Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors