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