Led the implementation of a Medicaid program in two states for a large integrated national health plan.
Implementation included developing business requirements, policies and procedures, workflows, staffing plans, identifying and coordinating cross-dependencies, and supporting the readiness review to meet the state contract requirements. Managed and coordinated across 13 work streams to ensure a successful implementation.
Provided oversight for creation of a new behavioral and physical health plan to implement a Medicaid program supporting severely mentally ill members.
This included managing development of policies and procedures (P&Ps), workflows, and desktop procedures as well as a future state implementation roadmap.
Provided program management to redesign a state Medicaid program which covers approximately 1.1 million members.
Project included assessing the model and structure of the state's current Medicaid programs, conducting a national environmental scan of Medicaid programs, developing options for redesign or modification to the current program, and assisting in the procurement and implementation of the desired solution.
Conducted business and organizational assessment of a large hospital and physician network seeking to become an accountable care organization (ACO).
As part of assessment, conducted a feasibility study of partnering, buying or building an insurance subsidiary. Developed people, process and technology recommendations for the hospital and physician system to evolve into a quality and cost-based revenue and delivery model. In its first year of operation, the system received $14 million back from CMS shared savings, generating total savings of $28 million. This was third largest payment among participating ACOs in the US.
Developed an ACO strategy for a board comprised of hospitals and physicians in a four state region.
Strategy included integration, technology and administrative needs to support patient population management and coordination. Performed an organizational, clinical, operational and technological capability assessment to inform an implementation roadmap.
Led a large BCBS plan in the development of strategy to full migration of a major re-engineering and systems implementation, including:
- Development and implementation of systems and tools related to consumer-driven healthcare (health statements, drug pricing tool, Web-based educational tools).
- Development and implementation of strategy, data exchanges and new processes with vendors to meet new system requirements. This included the exchange of real-time data with vendors, data exchanges with ancillary providers, end-to-end design and migration of products, and data exchanges for the pharmacy vendor.
Re-engineered and deployed the BCBS Federal Employment Program's (FEP) legacy claims systems over a four-year engagement.
Results of the project included improvement in the client's auto adjudication rate, lowered administrative costs, increased overall functionality of the system, and Web enablement of the online data entry and customer self-service functions.
Led a radiology benefit management company in the following projects:
- Process improvement initiatives of the authorization processes and network operations/management processes. Identified improvements to make the processes more efficient in terms of cost, timeliness, and quality, resulting in $4-6 million in annual administrative cost savings.
- Independent audits of several of the company's clients to evaluate the extent to which the company is meeting contractual obligations as well as compliance to state and federal regulations.
- Supported development of a strategy to implement a proactive, enterprise-based quality program with strong quality assurance and process improvement components.