Health Plans Consulting: Overview
People, process & technology working together to address real-world challenges
Health plans today are experiencing significant disruptions to their business models due to the COVID pandemic, adoption of virtual care models, emergence of the gig economy and an increase in Medicare members. The industry is also redefining operating models, with a strong push to value-based care, interoperability (including FHIR) and the use of digital technologies for member engagement, decision support and performance management.
This is where FluidEdge makes a significant impact. Backed by CitiusTech’s technology leadership, we are well equipped to support health plans as they navigate a complex, technology-enabled and member-centric journey to better outcomes. Our strategic consulting services help customers reduce costs, improve member experience and enhance the quality of care while staying aligned to long-term business objectives.
We thrive in the trenches
Through a strong team of experienced consultants drawn from core health plan processes, FluidEdge has the brainpower and scale to bring our customers' business plans to life. Our clients look to us first to help with strategy, operational analysis, regulatory compliance, quality programs, technical evaluation and project management.
Health Plans Consulting: Focus Areas
Through our partnership with CitiusTech, we offer comprehensive consulting services and technology solutions, to drive digital innovation for health plans and provider-aligned payer organizations.
FluidEdge has proven experience in helping payers comply with government mandates. We have robust frameworks to help you standup, manage and expand your government related lines of business.
- Compliance audits
- Market expansion strategy
- Product consulting
- Network adequacy
- Risk adjustment and revenue maximization
- STARS analysis
- ACA implementation
We help customers address regulatory needs using specialized technology platforms such as STARs Decision Engine (STARs ratings), BI-Clinical (State Medicaid measures), FAST+ for (CMS IPA Rule Compliance).
Operational Services & Transformation
We have highly experienced consultants who have run health plan operations for several years, giving us deep insights into key processes, challenges and potential solutions.
We have s structured approach to organizational change management, with significant expertise in:
- Organizational readiness assessment
- Training – content creation and delivery
- Program and project management
- Inventory management
- Maximizing claim auto adjudication
- Provider credentialing and network management
- -Operational optimization, best practices
- -Grievances and appeals
- -Customer relationship management
We have worked across an extensive set of clinical services in health plan organizations. We have experienced executives, nurses and care managers with a strong understanding of:
- Population health / Value-based program design
- DM / UM / CM strategies and implementation
- Patient risk modeling
- Clinical systems implementation
- Clinical staff augmentation
- NCQA accreditation
Through our partnership with CitiusTech, we bring industry-leading solutions for HEDIS/quality management, STARs Improvement, population health metrics and reporting/decision support.
Technology & Innovation Strategy
With CitiusTech, we are one of the world’s leading providers of healthcare technology solutions. We have driven strategic partnerships and digital transformation programs with health plans of all sizes. We have strong consulting and implementation experience with:
- System and BPaaS vendor selection
- IT organization optimization, architecture, technical roadmaps
- EDW design and delivery
- System / data integration, including FHIR
- Data analytics including assessment, design and testing
- Security and HIPAA compliance
- Cloud readiness assessment and migration strategy
By leveraging CitiusTech’s digital technology expertise, we offer customers a unified solution for digital innovation, by enabling rapid prototyping, Cloud, Big Data, FHIR, AI/ML models, RPA, etc.
Payer / Payvider Core System Services
We have deep expertise in assessing, implementing and supporting core payer systems, which include some of the leading platforms available today. Our comprehensive core system services include:
- Current & future state analysis (Business & systems)
- Vendor selection / RFP process
- System architecture and configuration
- Data management / Data quality analysis
- Testing – strategy & management
- Solution optimization
- System upgrade management
Through our partnership with CitiusTech, we design, build and implement ancillary end user applications, analytical systems, data warehouse and reporting solutions for our customer’s unique needs.
Meet our consultants
Know more about our business consulting services and technology solutions.
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