PacificSource Health Plans

Customer Support

• Provide excellent customer service primarily by telephone to all PacificSource customers
• Assist customers with coverage/claims related questions
• Accurately interpret benefits and policy provisions for all PacificSource products
• Conduct appropriate research and follow-up for prompt resolution of disputed claims
• Work efficiently in a high volume call center while maintaining a professional, positive, and caring demeanor
• Assist callers with coverage related questions/concerns; accurately interpret policy provisions for assigned products
• Analyze customer’s inquiries and determine correct steps for resolution, interpret benefit information, and claims processing accuracy
• Keep resource information up to date and well organized
• Document calls in a clear and consistent manner in computer system
• Conduct appropriate research, take ownership and follow through for prompt resolution of disputed claims

Customer Support Representative

Manager

• 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—while continuously refining 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, ensuring timely investigation, documentation, and resolution.
• 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, providing training and oversight to internal teams and vendors.
• 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 such as AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.
• 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.
• Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budgets. 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.
• Responsible for process improvement and working 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.
• Actively participate as a key team member in Manager/Supervisor meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• 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.

Manager, Payment Integrity

Sales

• Represent PacificSource in the marketplace and the broader business community.
• Responsible for training, support and performance of PacificSource Sales Representatives and Account Managers.
• Oversight of solicitation, sales, and retention of clients to achieve growth and financial performance goals of PacificSource Health Plans.
• Build positive broker relationships in the assigned region(s); assure education of distribution channel regarding company products and services.
• Provide direct sales and service to employers when required.
• Coordinate with and assist the Sales and Marketing Department to determine customer needs in the assigned sales territories.
• Supervise training and assignments of Sales Executives and Account Managers and regional personnel.
• Conduct regularly scheduled staff meetings to ensure current knowledge of sales goals, promotions, advertising, new products, marketing policies, etc.
• Assure timely turnaround on quotes and proposals.
• Oversee development, execution, and progress toward Target Account Strategy.
• Serve as an escalation point to investigate unresolved client complaints/concerns.
• Establish and maintain positive relationships with consultants/brokers to promote PacificSource Health Plans products, services, and team members.
• Organize and lead the Producer or Broker Advisory Council meetings.
• Work directly with Senior Vice President of Sales, and other senior executives, to achieve growth and profitability goals of PacificSource Health Plans.
• Facilitate negotiations for group renewals.
• Set, monitor and report Sales Goals, according to standard protocols established.
• Oversee communication and sales methodology in deploying community health plan model in designated geographic territories.
• Establish and maintain relationships with vendors and business partners providing products and services sold by PacificSource Health Plans.
• Review complete agent licensing assignments and forward for processing.
• Complete new business commission information and forward for processing.
• Analyze underwriting income by market segment.
• Represent PacificSource at community events and functions.
• 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.
• Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budgets.
• 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.
• Responsible for process improvement and working 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.
• Actively participate as a key team member in Manager/Supervisor meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Customer Support Representative

Manager, Payment Integrity

Regional Sales Director