Prepared multi-state Payer for organizational change to align to the changed ACA market landscape.
Led effort to drive organizational and operational change resulting from ACA across all critical functional areas including product development, enrollment, billing, claims adjudication, customer service, and sales. Developed an innovative process to facilitate change within the day-to-day business and technical teams for a $40M yearly ACA program. Focused on macro-level organizational redesign and micro-level changes, including translation of core functionality to business and technical operations.
Managed $20M program to implement a complete overhaul of a multi-state Payer’s products and benefits offerings ahead of ACA Public Exchange rollout.
Project required balancing complex scope with heavy risk due to uncertainty in Federal and State regulations. Responsibilities included executive engagement, program and project organization, budget forecasting and management, risk mitigation, and accountability for overall program delivery. Project required real-time business process development and implementation and organizational alignment for a highly cross-functional and complex product and benefit implementation process.
Designed and implemented product and benefit implementation and quality assurance management process to align to ACA mandated benefits and timeline.
Developed process to track and manage the implementation of 500+ distinct health plan designs across multiple market segments. Organized an implemented a repeatable quality review for benefit design documentation for internal payer and external customer usage. Managed build, validation, and testing for implementation of 500+ Exchange medical products and developed repeatable year-over-year process to transition to day-to-day client operations.
Assessed a regional payer’s benefit management and communication process to establish repeatable practices accounting for the entire implementation lifecycle.
Work included a people, process and technology assessment of the existing cross-functional product launch process. Facilitated sessions with more than 10 functional areas to create current state process flows and narratives, identifying organizational, technical and tactical pain points. Developed a new operating and governance model capable of flexibility, maximum implementation coverage, and rigid quality standards. Established a roadmap to evolve the organization away from its current fragmented approach.
Managed regional BlueCross plan through the concurrent transitions to NASCO and to integrated pharmacy and medical products.
Improved processing and administration of integrated pharmacy and medical plans and concurrent migration to NASCO through a 3-phased approach including assessment, requirements, and implementation. Performed an end-to-end current state analysis, future state development, and gap analysis across people, process and technologies. Developed business requirements and implementation road map to support desired future state. Implemented recommendations to improve Pharmacy Benefits Management (PBM) integration in accordance with a carefully orchestrated roadmap to the future state.
Assessed accuracy of hospital and provider claims payment to recover multi-million dollar overpayments.
Performed fast paced review and analysis of contracting practices, claims processing standards, and claim payment analysis. The claims payment analysis focused on identifying root cause for inaccuracies by developing hospital-specific pricing tools to systematically compare expected contracted rates to actual paid rates and by reviewing all hospital contracts to provide industry best practice and data-driven recommendations based on identified claims leakage. As a result of the team’s analysis and review, the Medicaid HMO identified over $1.7M in potential financial gain.