Care Management System

(May 2019–Jul 2020)

 

KEY BUSINESS RESULTS DELIVERED​

Course corrected an enterprise-critical implementation in distress, leading to successful delivery. Led strategic transformation, increasing operating margin and improving overall customer experience. Established a very strong results-oriented engagement between the client and its software partner.  ​

 

ENGAGEMENT SUMMARY​

Led program effort to assess and recommend course correction for inflight Care Management System Implementation, creating an integrated set of project plans to re-structure and re-launch the program.  Provided roadmap program governance, project plans with phased approach, alignment of vendor relationships and technology solution ownership, provided business operational readiness alignment of agile and traditional waterfall methodologies to reduce project conflicts and options to increase the speed of delivery of the program. ​
 

 

Enterprise Operational Assessment​

(Aug 2018–Jan 2019)​

 

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. ​

 

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Claims System Optimization

(Nov 2019–Current)

 

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. ​

 

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Pharmacy Benefits Management

(Apr 2019–Feb 2021​)

 

KEY BUSINESS RESULTS DELIVERED ​

Implemented program enabling real-time processing capability. Decreased issues related to handling of pharmacy claims and overcharge of out-of-pocket costs. Increased visibility into pharmacy claims details to improve member satisfaction. Streamlined internal processes to support data exchange with PBM to reduce health plan’s administrative costs.  ​

 

ENGAGEMENT SUMMARY ​

Led re-implementation and modernization of Pharmacy Benefit Manager (PBM) data exchange with contracted vendor. Modernization included adaptation of NCPDP standards when applicable, and integration with and deployment of new vendor tools to enable real-time processing capabilities. Program included six projects: Accumulator Exchange, Eligibility, Medical PA Eligibility, Portals/API, Billing, and Automated Benefit Build of benefit structures within the PBM system.

 

 

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Medicare Advantage Migration

(Aug 2019–Mar 2021)

 

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.

 

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Facets Stabilization & Optimization

(May 2018–current)

 

KEY BUSINESS RESULTS DELIVERED ​

Decreased provider data maintenance backlog (92%), decreased configuration backlog (43%), improved processing of Mass Claim Adjustments for a payout of ~$25m, reduced claims inventory (60%), and decreased provider appeals (95%) within a 5-month timeframe.  As a direct result 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.

 

ENGAGEMENT SUMMARY ​

Managed and led cross-functional team of subject matter and Facets experts to provided root cause analysis and correction related to a high volume of claims backlog resulting in the plan’s failure to meet Prompt Pay measures and resulting in a large backlog of provider and member appeals and grievances. Used a hybrid of Agile and Waterfall methodologies and Six Sigma Kaizen process improvement practices used to completed over 100 separate initiatives within the Stabilization project. Applied best-practice solutions to modify pre-adjudication logic, configuration, and business processes, bringing resolution to the issues creating the most significant errors.

 

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Product Modernization Program & Testing

(Oct 2018–Jan 2020)

 

KEY BUSINESS RESULTS DELIVERED ​

​​Merged code bases for the Enrollment, Billing and Claims products to use a common code base.  Upgraded legacy infrastructure components and deployed to a cloud environment.  Improved and stabilized the product application architecture as part of the implementation. Implemented automated monitoring and notifications of mission critical batch jobs. Projected year over year cost savings of $ 8.65M began to be realized in early 2020.

 

ENGAGEMENT SUMMARY ​

Led program consisting of 12 projects focused on implementation of a companywide technology upgrade. Managed interdependencies between the projects. Organized the program into three phases: migration of core products and automation of operational processes; merging of disparate code bases into a common code base; implementation of user-centric enhancements to core products.