health-plans

Health Plans
Case Studies

CM & UM System Implementation

Summary

FluidEdge Consulting assisted a health plan with a full operational redesign, complete system selection, implementation and training. Through our efforts, the health plan saw its operational efficiencies maximized, and more.
 

Challenge

  • A medium sized health plan needed experienced clinical, operational and process resources to lead the effort of a full operational redesign
  • The health plan required an assessment of multiple areas, including clinical, operational, process and technical followed by the development of a roadmap for execution
  • This client also needed external resources to lead and complete system selection and implementation
  • The health plan also needed a third party to train their internal team about care management activities and how to incorporate the new system into business workflows

Approach

  • We developed new processes and procedures for the delivery of care management to members
  • We developed new criteria and processes for utilization management
  • We created and delivered an overarching training plan to the clinical staff
  • We created and executed an overarching test plan
  • We provided detailed documentation for process flows and desktop procedures

Results

  • We reduced the number of authorizations required for standard services, focusing only on outliers
  • Our team redesigned workflows to maximize operational efficiencies and improve productivity
  • We provided improved access to the most recent clinical necessity criteria to improve decision making
  • Our team improved population management decision, making it more focused on high-need members