Services
Clinical Management
Guide members to the right care at the right time while accelerating financial and operational improvements with an integrated clinical management program.
Clearlink can help you identify opportunities to adopt transformational, holistic clinical solutions, even for the most complex populations.
Optimize existing clinical management processes to enhance programs with individualized, effective strategies. Get the expert guidance and ongoing support you need to generate best-in-class outcomes, decrease total cost of care, and continuously accelerate financial performance defined by key metrics.
All service areas can be facilitated by the rapid deployment of dedicated project teams and interim leadership to ensure the execution of mission-critical initiatives.
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Population Health Management
Population Health Management
Take a holistic approach to developing a tailored care model that improves the health and well-being of defined populations and subpopulations. Clearlink employs targeted programming for integrated, coordinated care to enhance engagement, health outcomes, and financial incentives and rewards. Through an effective population health management program that focuses on population health strategy, cost of care, and member experience, organizations can lower overall healthcare spend and improve the health and well-being of members by ensuring high-risk members receive the right care, at the right time, in the right place.
Key Services
- Identify, stratify, and support the management of complex and high-risk populations
- Move population health management program performance to industry best practices
- Evaluate, develop, and redesign transitions of care programs
- Implement plans for readmissions and optimal place of care
- Advise on special needs and dual-eligible member programs
- Provide guidance for case management strategy for Medicaid and government programs
- Offer guidance on clinical platform design, implementation, optimization, and operations
- Deliver population health analytics to identify and highlight new opportunities
- Support compliant, high-quality strategies for coordination of care in all lines of business
Care Management Program Design
Care Management Program Design
Design your care model, clinical programs, and targeted interventions to the specific populations, products, and markets you serve to manage affected members and ensure engagement. Clearlink can assure care management platforms support industry best practices, appropriate automation, and compliance with accreditation standards, regulatory requirements, and reporting needs.
Key Services
- Support for rebuilding care management program foundations on LOB regulatory requirements and NCQA standards
- Develop algorithms and risk stratification methodologies to identify at-risk populations
- Develop appropriate staffing models, plans, and staff auditing programs based on population characteristics and risk tiers
- Establish care management training curriculum for initial and ongoing support
- Develop leadership dashboards to manage daily operations, Key Performance Indicators (KPIs) and care management staff performance
Behavioral Health Integration
Behavioral Health Integration
Improve care outcomes and reduce total cost of care for your highest-risk populations with complete integration of behavioral and physical healthcare. Clearlink’s experts collaborate with organizations to evaluate current integration efforts and opportunities to offer solutions that help consistently achieve financial and operational improvements at a reduced overall cost. Whether implementing new populations or insourcing from vendors, you’ll get the guidance and project expertise needed to carve-in the management of your behavioral health members and benefits.
Key Services
- Assess current behavioral health integration practices
- Build robust patient identification and risk models to determine the physical, behavioral, and social health factors impacting population health and wellness
- Establish integration roadmaps to deliver strong programs and processes and lead successful implementation
- Offer guidance through interdisciplinary teams of clinical specialists focused on holistic care
Medical Cost Containment (UM)
Medical Cost Containment (UM)
Link regulatory compliance, utilization management, and member and provider satisfaction together for ideal financial performance and appropriate care access. Clearlink can help organizations evolve their utilization management policies, procedures, and compliance efforts to improve care outcomes, staff productivity, provider relations, and medical-necessity review quality, which impact medical loss ratio.
Key Services
- Assess current utilization management performance against best practice indicators, industry benchmarks, and clinical policy
- Provide methods of tracking and reporting ROI for cost containment efforts
- Evaluate data trends to identify key cost drivers and opportunities for savings across the care continuum
- Offer innovative prior authorization strategies
- Evaluate opportunities for automation of standard work and integration of machine learning into medical management processes
- Develop roadmaps to ensure care for the right members at the right time and place
- Expedite access to care and consider low-cost alternatives where appropriate
Grievances & Appeals
Grievances & Appeals
Design Grievances and Appeals (G&A) processes that deliver timely, fair, unbiased, and appropriate resolution necessary for compliance. Clearlink can help you successfully manage this area of health plan risk. With the ability to address claims of dissatisfaction and requests for reviews of actions in a timely manner is central to protecting member rights, ensuring appropriate care, and promoting provider satisfaction.
Key Services
- Manage grievances and appeals through procedure and process design, structured workflow development, and work queues for timely management
- Conduct staff training to support effective identification and resolution
- Develop documentation standards, monitoring tools, and quality review processes that support timely resolution and regulatory reporting
- Conduct root cause analysis and develop performance improvement plans to reduce risk
- Develop culturally, linguistically appropriate G&A communication with oral, written, and language assistance
Regulatory Compliance & Accreditation
Regulatory Compliance & Accreditation
Support intelligent audit preparedness by bridging the gap between regulatory adherence theories and real-world practice. Clearlink provides customized strategies that reveal opportunities to remedy issues with accreditation and compliance knowledge gaps, insufficient personnel, faulty processes, and lack of technical resources. Become equipped with the information, tools, and readiness plans needed to create organizational alignment with regulatory requirements and standards.
Key Services
- Conduct comprehensive readiness assessments to evaluate the current state of relevant people, processes, and technologies
- Utilize NCQA standards, guidelines, and interactive review tools to survey organizational compliance and audit readiness
- Leverage healthcare analytics to support advanced statistical analysis and predictive modeling for thorough evaluation and technical inquiries
- Recommend specific solutions and roadmaps to address challenges and drive impactful monitoring change
Quality Program Improvement
Quality Program Improvement
Implement a solid framework for quality improvement strategies that enhance your organization’s technology, culture, leadership, affordability, and human capital. With direction from the Clearlink team, you can more easily demonstrate systematically improved care, standardized processes, and reduced variation, leading to high reliability with predictable results. Achieve organizational targets and create value for stakeholders by capturing at-risk revenue and obtaining new financial incentives.
Key Services
- Conduct quantitative and qualitative data-driven analysis and reporting to drive meaningful quality improvement frameworks
- Measure quality management performance against key metrics and industry benchmarks to encourage sustainable, improved outcomes
- Accurately trend, track, and quantify the impact of all quality program improvement initiatives
- Provide optimized reporting for population health, health disparities, patient impact, compliance, accreditation, and cost of care
- Guide process development for quality accreditation, quality governance, quality measurement and reporting, alignment and standardization, affordability and adverse risk, compliance, and continuous improvement
Clinical Application Support
Clinical Application Support
Adopt data-centric application designs to guide streamlined workflows, eliminate duplicate efforts, automate processes, and achieve next-level reporting. Clearlink closely collaborates with organizations to assess current tools and technologies and make adjustments to promote cross-functional transparency, well-structured clinical and operational processes, and quality outcomes.
Key Services
- Evaluate current system operations, functionality, and ability to enable workflows and processes
- Support smart system selection and advise on system design, testing, and implementation to ensure functional and technical aspects meet user needs
- Facilitate system development to support evidence-based practice in a streamlined model, leveraging automation and machine learning where possible
- Implement systems to support centralized data collection and reporting for efficient processes and quality outcomes
Risk Adjustment Optimization
Risk Adjustment Optimization
Accurately capture and report member health conditions, health statuses, and population demographics to encourage appropriate risk adjustment. With the primary goal to provide funding that covers necessary expenses for member management, Clearlink’s solutions also create a clear baseline to assess quality and efficiency performance. Gain visibility into members across the care continuum and better evaluate the health and financial costs associated with how health plans identify and address current and future member needs.
Key Services
- Perform robust risk adjustment analytics to increase the predictability of member care and build knowledge across member populations to manage total cost of care
- Quickly and accurately identify member populations and care trends
- Support personalized care planning and coordination for members at risk of rising costs
- Design efficient care models and targeted intervention programs
- Advise on the best steps to increase member engagement and enter and manage value-based contracting strategies
Pharmacy Spend Management
Pharmacy Spend Management
Evaluate pharmacy spend with the help of experienced pharmacy operations consultants through formulary benefit design, oversight, and management that identifies areas for improvement and health plan savings. Pharmacy spend is the fastest growing sector of healthcare cost, and Clearlink can help organizations take a proactive approach to pharmacy benefit and associated program design and compliance to meet obligations, decrease liability, control risk, lower costs, and improve efficacy for members.
Key Services
- Evaluate served populations, utilization patterns, and outcomes
- Support effective formulary and pharmacy benefit design, oversight, and management to ensure cost-effective medication access for members
- Defining a strategy for specialty drug spend and assistance with implementation of key initiatives designed to manage this key risk area
- Create cost containment strategies and support pharmacy benefit management strategy and selection
- Aid specialty drug management and innovative clinical programs, such as medication reconciliation and medication therapy management
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