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Case Studies

Enhanced Utilization Review

A public, not-for-profit Medicaid HMO plan sought help conducting an end-to-end assessment of its utilization management (UM) department to improve the effectiveness and efficiency of its operations. With an outdated medical management system and no clear method of determining productivity success, meeting compliance requirements, and following quality measures, the health plan needed support in adopting reporting tools, aligning processes, and upgrading technology solutions.

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Case Studies

Prepared Population Health Management

A regional health plan was challenged by its board to adapt a community-based, neighborhood model to care for more complex, high-need, high-utilization, underserved populations, including ABD, LTSS, LTC, SMI, and IDD members as well as dual eligibles and foster children. The health plan needed to successfully demonstrate its ability to identify and manage risk, coordinate care, ensure access, deliver outcomes, and decrease costs for various member cohorts.

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Case Studies

Compliant Case Management

A community-based care delivery organization holds a new delegation contract with a regional health plan to provide case management services for Special Needs Plan (SNP) members. In order to receive an additional assigned cohort of Severely Mentally Ill (SMI) members, the care delivery organization needed to demonstrate its ability to transition members incompliance with all NCQA standards, state regulations, and contractual requirements.

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Case Studies

Optimized Delegation Oversight

The health plan division of a large, integrated care delivery system sought help in performing delegated oversight management for its government and employer programs. The team needed assistance centralizing an enterprise governance model designed to facilitate a strategic delegation oversight and vendor management program.

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Case Studies

Simplified Health Plan Accreditation

The health plan division of a large, integrated care delivery system sought support in developing a health plan accreditation readiness strategy for its government and employer programs.

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