PacificSource Health Plans

Team Leader

• Supervise and guide assigned team members on 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 submit 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-to-one meetings with assigned staff
• Assist the Manager with staffing, training, process improvement, and department budget assessment
• 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 relevant communications to management, teams, and departments
• 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
• Oversee hiring, staff development, coaching, performance reviews, corrective actions, and terminations
• Investigate and resolve provider data issues, escalating information as needed
• Oversee compliance and quality of provider data related to NCQA, OHA, CMS, WAOIC, and other standards
• Meet department and company performance and attendance expectations
• Follow PacificSource privacy policy and HIPAA confidentiality and security requirements
• 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 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 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 case-management/care-coordination meetings
• Maintain compliance with state and federal regulations, HIPAA standards, confidentiality, and accurate 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, and projects
• Support care management quality measures required by government regulations
• Enter and collate data and prepare assigned reports
• Participate in requested committees
• Make small-group presentations
• Participate in quality-improvement initiatives
• Perform other duties as assigned

Member Support Specialist

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 partnerships within HR and business units
• Develop practices that create an exceptional employee experience
• Assist the organization in driving business objectives and managing change
• Execute practices across organizational development, succession planning, workforce development, employee retention, organization design, and change management
• Identify training needs and individual executive coaching needs
• Foster an employee-oriented culture focused on 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
• Use analytics to assess business issues, identify root causes, and implement solutions
• Develop relationships with internal and external stakeholders
• Partner with stakeholders to develop workforce diversity strategies
• Participate in developing department goals, objectives, and systems
• Monitor organizational culture and employee satisfaction
• Maintain and update required federal and state postings
• Meet department and company performance and attendance expectations
• Follow PacificSource privacy policy and HIPAA requirements
• Assist with special projects and perform other assigned duties

HR Business Partner

• Develop and implement HR practices and strategies aligned with business objectives
• Act as a consultant to business partners through partnerships within HR and designated 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
• Serve as primary point of contact for leadership and employees in assigned departments
• Understand business units and their strategic initiatives
• Provide guidance on workforce planning, strategy and 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
• Develop practices, procedures, and guidelines aligning the workforce with organizational strategic goals
• Use analytics to assess business issues, identify root causes, and implement solutions
• Disseminate information to appropriate audiences
• Develop and maintain internal and external stakeholder relationships
• Work with other HR functions to ensure consistent practices, policies, and procedures
• Develop a diversity strategy that fosters inclusion
• Participate in developing department goals, objectives, and systems
• Monitor organizational culture and employee satisfaction
• Maintain and update required federal and state postings
• Assist with special projects and perform other assigned duties

• 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 business units
• Develop practices that create an exceptional employee experience
• Assist the organization in driving business objectives and managing change
• Identify trends and issues and develop integrated solutions with internal and external stakeholders
• Execute HR practices 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 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 governmental, labor, legal, and 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 and maintain internal and external stakeholder relationships
• Collaborate with HR functions to ensure consistent practices, policies, and procedures
• Develop a diversity strategy that fosters workforce inclusion
• Participate in department goals, objectives, and systems
• Monitor organizational culture to support company goals and employee satisfaction
• Maintain and update required federal and state postings
• Meet department and company performance and attendance expectations
• Follow PacificSource privacy policy and HIPAA laws concerning protected health information
• 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, assigned projects, compliance initiatives, and operational initiatives
• Perform other duties as assigned

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 across health and human services and care settings
• Coordinate with clients, payers, primary care providers, and other service-delivery professionals
• Maintain client privacy, confidentiality, health, and safety while adhering to ethical, legal, accreditation, certification, and regulatory standards
• Answer medical or contract-interpretation questions referred by other departments, physicians, and providers
• Assist employers and agents with healthcare-resource and procedure questions
• Practice 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 confidentiality and security requirements
• Perform other duties as assigned
• Travel approximately 5% of the time

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
• Ensure care is safe, effective, client-centered, timely, efficient, and equitable
• Communicate with clients, payers, primary care providers, and other service professionals
• Maintain client privacy, confidentiality, health, and safety in accordance with applicable standards and regulations
• Answer medical or contract interpretation questions from internal 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