PacificSource

The Program Manager is primarily responsible for designing, implementing, and managing the company’s Fraud Waste and Abuse (FWA) Program, providing expertise for tracking, investigating, and managing suspected FWA complaints. This role involves building the FWA structure with policies and procedures, chairing the Program Integrity Committee, and ensuring compliance with state and federal FWA requirements through monitoring and reporting.

This role leads the strategic design, implementation, and execution of Payment Integrity programs to improve payment accuracy and member affordability, serving as a key liaison for reimbursement policy and PI initiatives. Essential duties include overseeing pre- and post-payment programs, managing external vendors, directing FWA detection, and ensuring compliance with coding and regulatory guidelines.

Clinician Care Managers facilitate client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. They develop comprehensive, individualized care management plans promoting appropriate utilization and cost-effective care by linking clients with appropriate resources.

The Senior Director is responsible for leading teams in product lifecycle management for Medicare and commercial lines, efficient business administration, and compliant regulatory communications, ensuring products meet membership and profitability targets.

The Senior Director is responsible for leading teams in product lifecycle management for Medicare and commercial lines, efficient commercial business administration, and compliant regulatory communications, ensuring products meet membership and profitability targets.

The role involves conducting pre, post, and focused audits, handling the clinical component of appeals, and developing/reviewing policies and desktop references, requiring collaboration with internal departments to ensure regulatory adherence.

This role leads the design and execution of an integrated, enterprise-wide care management model across all lines of business, overseeing risk-tiered programs like Transitions of Care, Case Management, and Disease Management. Key duties include ensuring high-quality, cost-effective care delivery that improves health outcomes, enhances member experience, and meets regulatory standards.

This role is accountable for the effective management of Special Functions staff, including hiring, training, coaching, and performance evaluation, while actively participating in program development and implementation. Responsibilities include supervising staff, managing workflow quality and productivity, resolving issues, and improving processes and outcomes for assigned functions.

This role is responsible for improving, developing, and implementing initiatives to execute clinical pharmacy strategies, supporting the Vice President of Pharmacy Services in executing cost of care strategies, strategic roadmaps, and quality initiatives impacting STARS rating and HEDIS measures. Key duties involve cross-departmental collaboration to analyze, design, and implement infrastructures for programs that optimize medication use and support CMS STAR ratings and PQA performance measures.

This role is responsible for improving, developing, and implementing initiatives to execute clinical pharmacy strategies, supporting the Vice President of Pharmacy Services in executing enterprise cost of care strategies, strategic roadmaps, and quality initiatives impacting STARS rating and HEDIS measures. Key duties involve cross-departmental collaboration to analyze, design, and implement infrastructures for programs that elevate clinical quality, optimize medication use, and support CMS STAR ratings and PQA performance measures.