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Clinical Care Management Programs
KEY BUSINESS RESULTS DELIVERED
Re-designed clinical care programs for health care company delivering high-touch, specialized care at home to patients at an elevated risk for an emergency event or hospitalization due to complex, chronic illnesses, complicated by social determinants to health and other barriers to care. The clinical re-design enables a stronger market position through expanded care services and reduces costs associated with avoidable hospitalizations and ER visits.
ENGAGEMENT SUMMARY
Led project to assess current clinical care offerings, developed a strategy for condition expansion, and deployed comprehensive clinical care programs, increasing clinical service coverage for members, enabling business growth and development. Provided program descriptions and evidence-based interventions that meet accreditation standards. Developed standard operating procedures and policies & procedures, along with training materials, performance management tools, and technical capabilities assessment to ensure the clinical care re-design is successfully managed.
Claims System Optimization
KEY BUSINESS RESULTS DELIVERED
Created and put into execution a 2-year mitigation roadmap. Optimized the efficiency of the core claims system, saving year-over-year new FTE costs due to manual work. Reduced unnecessary customer claim pends, provider over payments and adjustments, and code-red production issues. Simplified product configuration, eliminating the need for an expensive and disruptive platform replacement.
ENGAGEMENT SUMMARY
Directed a 360-assessment of core claim processing system to drive critical business decisions. As a result of this assessment, a two-year roadmap was created outlining 40 high-impact opportunities to address technical improvements and business optimization. Provided program leadership and project resources to support execution of the roadmap.
CSNP Product Launch Assessment
KEY BUSINESS RESULTS DELIVERED
Through a deep dive holistic assessment of Senior Health Services operations, identified and documented all critical Medicare Advantage-related business processes, workflows, gaps, systems, data sources, standard operating procedures and fulfilment processes that would be impacted by the new product CSNP product. Provided a complete and actionable roadmap for a practical and compliant implementation of the product and the required Model of Care (MOC). Outlined recommendation for each gap identified. Assigned a level of effort and level of complexity for each recommendation. Identified resource types required to execute action. Recommended an approach to prioritizing remediation actions identified.
ENGAGEMENT SUMMARY
Performed a deep dive end-to-end assessment of current infrastructure, staffing, and processes against the requirements to implement a CSNP product within SHS Medicare Advantage. This assessment provided the data needed for client leadership to understand the effort, complexity, resources and cost required for a new product launch. The assessment captured opportunities and challenges across the organization in process, technology, data, and vendor services enabling the health plan to make an informed decision.
Enterprise Operational Assessment
KEY BUSINESS RESULTS DELIVERED
Delivered a quantified end-to-end enterprise view of all critical operational processes and the supporting tools, technologies, and data with particular focus on touch points impacting customers and brokers. Created a prioritized, multi-year mitigation plan addressing process, technology, and organizational gaps. Brought the company into compliance with audit requirements, reduced errors and drastically reduced workload for the configuration and testing teams with new processes and automation tools.
ENGAGEMENT SUMMARY
Performed a deep dive end-to-end assessment of technology, business engineering, processes, and communications requirements to meet new mandated audit measurements. Gap analysis outlining the health of over 200 processes were inputs to a road map supporting short- and long-term process improvement strategies. Recommendations included standardization of request documentation, process and procedure documentation and improved testing methods through automation and evidenced based review.
Third Party Administrator System Implementation
KEY BUSINESS RESULTS TO BE DELIVERED
Configuration and Implementation of new core operating system that will increase efficiencies for multiple operational areas: Flex benefits integration to Core system and removed from external application; stoploss reporting and management streamline; claims payment provided multi-thread processing capabilities; system file scheduling; and multi-thread processing capabilities. The new operating system affords the company additional benefits in automation of a number of current operational processes.
ENGAGEMENT SUMMARY
Led pre-implementation readiness project to create and assess baseline business inventory of all system configuration and reports as well as IS inventory of all applications, interfaces, and extracts. Worked with vendor to create overall project plan, leading the Operational and Testing workstreams. Provided BA support for various departments in process workflows, requirements documentation, and configuration. Extended Testing effort to the data migration conversion work stream and led effort of the overall conversion plan and execution, managing the internal resources, external contractors, and vendor representatives.
Supplemental Benefits Configuration Optimization
KEY BUSINESS RESULTS DELIVERED
Reduced the amount of configuration requiring maintenance by identifying criteria and prefix duplications. Created documentation standards to mitigate the level of maintenance effort and provide flexibility in configuring new concepts which were previously manual processes. Increased claims payment accuracy through deep dive review and cleanup of configuration. Increased data integrity – during analysis finding and resolving configuration inconsistencies and discrepancies. Enabled the ability to move configuration between environments utilizing automated tools. Increased efficiencies for future configuration requirements and build. Decreased number of unique values and time necessary to build.
ENGAGEMENT SUMMARY
Provided leadership, analysis and configuration expertise for the design and implementation of a multi-year Facets Table migration. Redesigned intake and prioritization process of configuration requests. Managed team through process of creating an automated tool to support the migration which decreased the manual analysis efforts by 75%. The Supplemental Procedure Conversion Rules application (“SPCR”) and Supplemental Revenue Code Conversion Rules (“SRCR”) enables configuration to establish a single set of rules that supports supplemental conversion for both Claims and UM processing. By utilization of Qualifier Groups (SCQG) the supplemental conversion has a single point of configuration for reusable criteria for multiple Lines of business.
Pharmacy Benefits Management
KEY BUSINESS RESULTS DELIVERED
Implemented program to unify and streamline processes under a single Pharmacy Benefits Management (PBM) vendor, creating an estimated $5.1M annual administrative savings for the health plan. Projected savings included a reduced cost for PBM services, and staffing reductions through elimination of redundant resource responsibilities.
ENGAGEMENT SUMMARY
Led migration of PBM vendor following acquisition of a small health plan by a mid-size health plan. Migration involved unification of formularies, pharmacy networks, benefits, and alignment of operational processes including delegation of specific processes to the PBM. The Program included six workstreams: Clinical Programs, Client Setup, Data Exchange, Member/Provider Experience, Operations, and Offboarding of prior PBM.
Hospital System Integration
KEY BUSINESS RESULTS DELIVERED
Upon Merger & Acquisition of large regional hospital systems, providing project management and leadership for the consolidation of all hospitals into one combined instance of Epic. This includes harmonizing high performing workflows, aligning policies and procedures and third-party applications and contracts across the organizations and ensured cross organizational access to legacy data and platforms.
ENGAGEMENT SUMMARY
Through program and project management, supporting the successful migration of 3 large hospital systems onto one EHR platform, providing a seamless patient experience across the state of Michigan.
Medicare Advantage Migration
KEY BUSINESS RESULTS DELIVERED
Provided leadership and technical oversight to successfully manage 500+ requirements to migrate the Medicare line of business by the end of vendor contract date to internal system where 100% of enrollments and all new claims and authorizations are managed. Maintained track record of member satisfaction and CMS compliance. With successful on-time completion of the migration phase of the program, the client is positioned to implement further process improvements with a goal of improving their Star ratings and increasing membership.
ENGAGEMENT SUMMARY
Managed strategic objective to migrate all business associated with Medicare Advantage (MA) HMO and PPO members from an external vendor to an internal acquired organization with a 4-Star CMS rating. Successfully supported the transition of multiple workstreams including claims and authorizations, enrollment, finance, appeals & grievances, medical management, pharmacy, provider data, and benefits.