PACIFICSOURCE

Team Leader

• Supervise and guide assigned team members regarding company policies, procedures, and workflow
• Set goals and implement strategies to ensure team members effectively assist providers with internal processes
• Manage hiring processes for Operations staff
• Coach employees to improve individual performance and develop teamwork
• Evaluate team member performance and conduct timely performance evaluations
• Maintain knowledge of assigned positions and develop ongoing training and coaching programs
• Supervise and evaluate data production and quality performance
• Conduct regular one-on-one meetings with assigned staff
• Assist the Manager with staffing, training, process improvement, and department budget needs
• Create and evaluate Operations production and data quality metrics
• Supervise development and maintenance of Provider Network job aids, policies, and procedures
• Liaise with PacificSource departments to coordinate service and information
• Attend and lead enterprise workgroups related to provider data scalability and quality outcomes
• Document and report pertinent communications to the manager, team, or department
• Lead continuous improvement efforts for enterprise and team processes
• Foster a positive virtual and in-person work environment, provide constructive feedback, and promote continuous learning
• Collaborate with leadership teams to develop best practices and address enterprise-wide process issues
• Handle hiring, staff development, coaching, performance reviews, corrective actions, and employee terminations
• Investigate and resolve provider data issues, escalating information as needed
• Oversee compliance of provider data quality with regulatory and marketability standards, including NCQA, OHA, CMS, and WAOIC
• Perform other duties as assigned

Provider Data Maintenance Team Leader

Customer Support

• Serve as a resource to members with complex psychosocial issues that create barriers to medical-regimen adherence and optimal health outcomes
• Work telephonically and in person as an integral part of the case management team
• Develop and implement member goals and plans in coordination with case managers
• Educate members about understanding and working within their benefit structure
• Use motivational interviewing and patient-engagement techniques to support optimal health outcomes
• Identify community resources and make appropriate referrals
• Serve as liaison between members and providers/agencies
• Identify members for coordination and case management services using claims data and reports
• Screen requests for appropriate case-management referrals
• Collaborate with the case management team and participate in care-coordination meetings
• Maintain compliance with state and federal regulations, HIPAA standards, and confidentiality requirements
• Maintain accurate and timely documentation
• Assist with referrals, appointment scheduling, and transportation to medical appointments
• Assist members with non-clinical needs during transitions and phases of care
• Manage mailing lists and outgoing mailings
• Assist with departmental procedures, reports, projects, and quality measures
• Enter and collate data and prepare assigned reports
• Participate in committees and quality-improvement initiatives
• Make presentations to small groups
• Perform other duties as assigned

Member Support Specialist

• Serve as a resource to members with complex psychosocial issues that create barriers to medical-regimen adherence and optimal health outcomes
• Work telephonically and in person to support members
• Coordinate with case managers to develop and implement member-specific goals and plans
• Educate members about their benefit structures
• Use motivational interviewing and patient-engagement techniques to support optimal health outcomes
• Identify community resources and make referrals
• Serve as liaison between members and providers/agencies
• Identify members for coordination and case management services using claims data and reports
• Screen requests for appropriate case-management referrals
• Collaborate with the case-management team and participate in care-coordination meetings
• Maintain compliance with state and federal regulations, HIPAA standards, and confidentiality requirements
• Maintain accurate and timely documentation
• Assist with referrals, appointment scheduling, and transportation to medical appointments
• Assist with non-clinical needs during transitions and phases of care
• Manage mailing lists and outgoing mailings
• Assist with departmental procedures, reports, and projects
• Assist care management with government-regulated quality measures
• Enter and collate data and prepare assigned reports
• Participate in team, department, company, and community committees
• Make presentations to small groups
• Participate in quality-improvement initiatives
• Perform other duties as assigned

Human Resources

• Develop and implement HR practices and strategies aligned with business objectives
• Ensure alignment between employees and management in designated business units
• Act as a consultant to business partners through HR and business-unit partnerships
• Develop practices that create an exceptional employee experience
• Assist the organization in driving business objectives and managing change
• Execute HR practices across organizational development, succession planning, workforce development, retention, organization design, and change management
• Identify training needs and executive coaching needs
• Foster an employee-oriented culture emphasizing quality, continuous improvement, high performance, and diversity and inclusion
• Serve as primary contact for leadership and employees in assigned departments
• Provide workforce planning, strategy, operations, and HR-practice guidance
• Provide day-to-day performance management guidance, including coaching, counseling, career development, and disciplinary actions
• Ensure compliance with employment laws, regulations, and government reporting requirements
• Partner with the legal department as needed
• Manage complex employee relations issues
• Use analytics to assess business issues, identify root causes, and implement solutions
• Develop relationships with internal and external stakeholders and coordinate consistent HR practices
• Partner with stakeholders to develop a workforce diversity strategy
• Participate in developing department goals, objectives, and systems
• Monitor organizational culture and promote employee satisfaction
• Maintain and update required federal and state postings
• Meet department and company performance and attendance expectations
• Follow privacy policy and HIPAA requirements for protected health information
• Assist with special projects and other assigned duties

HR Business Partner

• Develop and implement HR practices and strategies aligned with business objectives
• Ensure alignment between employees and management in designated business units
• Act as a consultant to business partners through partnerships within HR and defined business units
• Develop practices that create an exceptional employee experience
• Assist the organization in driving business objectives and managing change
• Execute practices and strategies across organizational development, succession planning, workforce development, employee retention, organization design, and change management
• Identify training needs for business units and individual executive coaching needs
• Foster an employee-oriented culture emphasizing quality, continuous improvement, high performance, diversity and inclusion
• Improve work relationships, build morale, and increase productivity and retention
• Serve as primary point of contact for leadership and employees in assigned departments
• Provide guidance on workforce planning, strategy, operations, and HR practices
• Provide day-to-day performance management guidance, including coaching, counseling, career development, and disciplinary actions
• Maintain compliance with governmental, labor, legal, and reporting requirements
• Manage complex employee relations issues and develop workforce-alignment practices, procedures, and guidelines
• Assess business issues, use analytics to identify root causes, and implement solutions
• Develop relationships with internal and external stakeholders and coordinate consistent HR practices
• Develop a diversity strategy that fosters workforce inclusion
• Participate in developing department goals, objectives, and systems
• Monitor organizational culture to support company goals and employee satisfaction
• Maintain and update required federal and state postings
• Assist with special projects and perform other duties as assigned
• Travel approximately less than 5% of the time

• Develop and implement HR practices and strategies aligned with business objectives
• Ensure alignment between employees and management in designated business units
• Act as a consultant to business partners through partnerships within HR and defined business units
• Develop practices that create an exceptional employee experience
• Assist the organization in driving business objectives and managing change
• Execute practices and strategies across organizational development, succession planning, workforce development, employee retention, organization design, and change management
• Identify training needs and executive coaching needs
• Foster an employee-oriented culture emphasizing quality, continuous improvement, high performance, diversity, and inclusion
• Serve as primary point of contact for leadership and employees in assigned departments
• Provide guidance on workforce planning, strategy, operations, and HR practices
• Provide day-to-day performance management guidance, including coaching, counseling, career development, and disciplinary actions
• Maintain compliance with governmental, labor, legal, and reporting requirements
• Partner with the legal department as needed
• Manage complex employee relations issues and develop workforce practices, procedures, and guidelines
• Use analytics to assess business issues, identify root causes, and implement solutions
• Develop relationships with internal and external stakeholders and coordinate consistent HR practices
• Partner with stakeholders to develop a workforce diversity strategy that fosters inclusion
• Participate in developing department goals, objectives, and systems
• Monitor organizational culture to support company goals and employee satisfaction
• Maintain and update required federal and state postings
• Assist with special projects and perform other assigned duties

Data Analyst

• Develop, maintain, and distribute payment integrity dashboards, reports, and performance scorecards
• Track and monitor recoveries, cost avoidance, savings, inventory, and operational performance metrics
• Analyze claims, provider, reimbursement, and audit data to identify payment integrity opportunities and emerging trends
• Support fraud, waste, and abuse detection efforts through data analysis and reporting
• Monitor vendor performance and validate reported recoveries, savings, and contractual performance measures
• Develop recurring operational, financial, and executive reporting
• Perform data validation, reconciliation, and quality assurance activities
• Support audit targeting, provider outlier analysis, and recovery opportunity identification
• Create ad hoc analyses and presentations to support leadership decision-making
• Partner with Information Technology and enterprise data teams to improve reporting capabilities and data accessibility
• Identify trends, risks, and opportunities and provide data-driven recommendations to leadership
• Assist with budgeting, forecasting, and performance measurement activities related to payment integrity programs
• Support regulatory reporting, audits, and documentation requests
• Participate in departmental meetings and assigned projects
• Participate in compliance and operational initiatives as needed
• Perform other duties as assigned
• Collaborate with Payment Integrity leadership, Claims Operations, Finance, Compliance, Information Technology, and external vendors

Payment Integrity Analytics Specialist

Clinician

• Facilitate client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation
• Collect and assess patient information to develop comprehensive, individualized care management plans
• Promote appropriate utilization and cost-effective care and services
• Link clients with appropriate providers and resources throughout health and human services and care settings
• Ensure care is safe, effective, client-centered, timely, efficient, and equitable
• Communicate with clients, payers, primary care providers, and other service delivery professionals
• Maintain client privacy, confidentiality, health, and safety through advocacy and adherence to applicable standards and regulations
• Provide quality customer service to PacificSource personnel
• Serve as an internal resource for medical or contract interpretation questions
• Assist employers and agents with healthcare resource and procedure questions
• Use effective written and verbal communication
• Utilize and promote evidence-based tools
• Utilize lean methodologies for continuous improvement
• Meet department and company performance and attendance expectations
• Follow PacificSource privacy policy and HIPAA laws and regulations
• Perform other duties as assigned

Care Management Clinician

• Facilitate client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management and service facilitation
• Collect and assess patient information to develop comprehensive, individualized care management plans
• Promote appropriate utilization and cost-effective care and services
• Link clients with appropriate providers and resources across health and human services and care settings
• Coordinate communication among clients, payers, primary care providers and other service professionals
• Maintain client privacy, confidentiality, health and safety in accordance with ethical, legal, accreditation, certification and regulatory standards
• Answer medical or contract interpretation questions referred from other departments, physicians and providers
• Assist employers and agents with healthcare resource and procedure questions
• Use evidence-based tools and lean methodologies for continuous improvement
• Meet department and company performance and attendance expectations
• Follow PacificSource privacy policy and HIPAA requirements
• Perform other duties as assigned
• Work in a general office setting and travel approximately 5% of the time