Facets Stabilization

Mid-Sized Regional Health Plan

May 2018-Current

Managed and led cross-functional team of subject matter and Facets experts to identify and resolve issues that were causing a large backlog of pended/errored claims in Facets, using a hybrid of Agile and Waterfall methodologies and Six Sigma Kaizen process improvement practices.  Resolution of issues included modification to pre-adjudication logic, configuration, and business process.  In total, over 100 separate initiatives were completed within the Stabilization project.  Significant outcomes included a decrease of provider data maintenance backlog (92%), decrease of configuration backlog (43%), processing of Mass Claim Adjustments for a payout of ~$25m, reduction of claims inventory (60%), and decreased provider appeals (95%) within a 5-month timeframe.  Because of the Stabilization initiative, the health plan was moved by the State from a “remediation” categorization to “stabilization”, allowing the plan to continue as the state’s primary Medicaid administrator.

Operational Process Assessment & Implementation

 

Large Regional Health Plan

June 2017-March 2018

Performed assessment of end-to-end provider reimbursement process, including Core Facets and NetworX configuration and quality assurance.  Documented and presented recommendation for modifying end-to-end processes to align with industry best practice and to minimize the risk of errors.  Led process improvement team to identify, write, and implement best practice standards for configuration and QA of Core Facets Pricing and NetworX, and facilitated cultural change to eliminate wasteful practices within the handling of configuration requests.  Worked with leadership to identify and implement methods for ongoing measurement of compliance to standard.  Developed training materials for roll-out of the revised process and trained impacted staff and leadership throughout the organization. 

Operational Readiness for a New System Implementation

Mid-Sized Regional Health Plan

February 2018 – August 2018

Initiated an operational readiness plan to be used during the implementation of a new, core care management system.  Using the ADKAR (Awareness / Desire / Knowledge / Ability / Reinforcement) approach, conducted an early risk assessment to categorize specific change plan needs, identified all stakeholder groups that would be impacted (including vendors and providers), documented early zones of resistance, and estimated the potential consequences of a poorly-management implementation.  The plan instigated a list of more-defined readiness activities, including a communications strategy specific to target audiences, including management and executives.

Customer Experience Assessment

Medium Regional Health Plan

July 2018 - Current

Administered a methodical approach singularly focused on creating a consumable output designed for enabling decision-making. The assessment of operational efficiency was based on review of process maturity, degree of application & technology debt, and workforce skills readiness.  Assessment was structured to enable objective and measurable health assessment of critical business processes and technologies that support them.  The outcomes included a visual heat-map depiction of the assessment results to enable easy review and prioritization.  The heat-map allowed a prioritized visual roadmap for a 3-year action plan.

Medicare Advantage Program

Mid-Sized Regional Health Plan

June 2017 - July 2018

Provided leadership for implementation of a new business unit that provided Medicare Advantage business processing outsourcing (Medicare as a Service).  The Program implemented cloud-based systems, security, and network infrastructure that provided core business capabilities such as Enrollment; Billing & Finance; Claims Administration, Customer Service; Data Warehouse; Medical Management; Provider Data Management; and Commissions.  Dozens of vendor integrations were implemented between the core and ancillary systems that included a program-level test strategy, test plan and test execution.

Care Management Vendor & System Selection

Mid-Sized Regional Health Plan

February 2018 – August 2018

Managed initiation and discovery phases of client’s core medical management system replacement.  The program’s scope required a robust system for case management, utilization management, behavioral health, and wellness for Medicare, Medicaid, and group and individual commercial lines of business.  Led a core team of procurement specialists, project managers, architects, and subject matter experts to identify key vendors, develop high-level requirements aligned with the organization’s capabilities model, identify technical system impacts, and establish methods to document business process flows.  Assisted in the design of the selection team’s methods, evaluation scorecard, and executive status presentations.  

Medicare Advantage Program

Mid-Sized Regional Health Plan

June 2015 – December 2016

Managed all aspects of Medicare Advantage implementation. Go-Live on time and under budget; provided post-implementation support including definition of operational organization and standard operating processes.

ACA Marketplace

Large Regional Health Plan

January 2016 – January 2017

Led program effort to integrate large health plan with an external vendor to support an ACA individual and small group Marketplace implementation. Managed integration of over 150 key business systems and processes that included project, vendor, and program-level testing.  Met aggressive dates and deliverables to allow successful Go-Live for Open Enrollment period.

ICD-10 Testing and Implementation

Large Regional Health Plan

April 2013 – December 2015

At peak, 25 consultants working on Neutrality/Equivalency and User Acceptance testing. Go-Live on time with minimal post-implementation issues.

System Optimization

Mid-Sized Regional Health Plan

June 2014-March 2017

Provided team of experts to configure, optimize and manage data/system integrity to ensure project integration and compatibility with core claim system.  Validated design and managed testing; provided impact analysis to operational and technical areas.