Operational Management

Program & Project Delivery

Obtain support in strategizing, planning, and delivering complex change initiatives. Clearlink can assist organizations in implementing project portfolio management with transparent oversight to ensure successful investments and business outcomes, directing efforts toward the right projects at the right times. We also help internal teams supplement their own project delivery capabilities and manage project management office responsibilities.

Key Services

• Develop and implement Project Portfolio Management (PPM) governance
• Assess and report on current project portfolios
• Define business outcomes and related project outcomes
• Define, implement, and improve demand management processes
• Assess or define project planning, forecasting, budgeting, change management, and oversight approaches and processes
• Identify and implement PPM processes, reports, and other tools to support initiative status and delivery transparency
• Augment project teams to provide expertise, fill capacity gaps, and facilitate key organizational initiatives
• Provide Project Management Office (PMO) services to organize, define, and manage project-focused work
• Assess organizational approaches and build roadmaps and resourcing plans for project-based initiatives

Payment Integrity

Build a high-functioning payment integrity program that delivers significant savings by avoiding inaccurate payments and managing claims properly for eligible members and covered benefits. Accelerate financial performance, tighten vendor relationships, and reduce payment errors over time. With Clearlink’s help, organizations can build mature internal processes that optimize health plan talent and resources, increase transparency with providers, and realize substantial cost of care savings.

Key Services

• Assess current payment integrity capabilities
• Evaluate, identify, and optimize payment integrity vendors
• Develop program roadmaps for optimized payment accuracy
• Guide claim payment processes to validate correct amounts and accurate coding
• Evaluate payment operations to protect against fraud, waste, or abuse
• Provide Project Management Office (PMO) services to organize, define, and manage project-focused work
• Assess organizational approaches and build roadmaps and resourcing plans for project-based initiatives

Provider Network Operations

Optimize your provider network program to broaden member access while decreasing costs, improving outcomes, and meeting managed care objectives. Clearlink can help health plans build partnerships with engaged providers rooted in value-based contracting strategies to promote access, quality outcomes, efficiency, and overall cost of care financial performance. We have the experts, resources, and agility to customize solutions across the provider lifecycle to augment existing networks, establish new ones, implement contracting strategies, maintain provider data accuracy, and maximize the value of provider relations.

Key Services

• Maximize the value of provider partnerships and network builds
• Improve innovative market and product contracting strategies
• Enhance provider network performance through data management practices
• Design new networks and augment existing ones

Product & Benefit Design

Successfully prepare for program developments, change announcements, and state and federal program policy changes that impact daily operations, business development, and strategic planning activities. Make use of Clearlink’s government program expertise to monitor and plan for business opportunities across the US related to federal and state program procurement opportunities.

Key Services

• Plan, design, and analyze data activities to develop new benefit offerings and manage, evaluate, and refine current benefit offerings
• Inform business development strategy and secure new growth opportunities
• Improve clinical and administrative efficiency
• Enhance existing programs, strategies, and solutions and maintain current business
• Maximize value as a partner in government programs

Healthcare Analytics Management

Harness data as a powerful tool to illuminate trends, performance, and opportunities across population health management, payment integrity, quality analytics, and operational performance. Clearlink can capture and analyze data and create helpful dashboards and data modeling tools to generate significant value and insight for strategy, plan development, and execution. This data can translate to member retention, new member enrollment, and improved revenue, among other valuable outcomes.

Key Services

• Identify high-risk members and support targeted care management
• Enable pre- and post-claims payment integrity data mining for over-payment, payment inaccuracy identification due to provider billing errors, contract compliance errors, coordination of benefits, eligibility errors, system limitations, or benefits policy rules
• Identify and close care gaps related to state-specific and CMS Quality System metrics (STARs)
• Enable data mining and modeling to assess current performance, identify objectives, and drive tactical execution focused on improved STAR performance and ratings
• Provide real-time insights into operational performance compared to key performance indicator targets, benchmarks, and best practices
• Support leadership management of performance, quality, and productivity
• Model data trends to proactively adjust staffing and workflows

Claims Configuration

Discover optimized systems engineering and machine learning solutions for establishing and maintaining consistency in core processes and supporting system attributes and interfaces. Optimized core platform configuration focuses on helping our customers establish strong configuration systems that help increase adjudication and payment integrity, member and provider satisfaction, value-based contracting, data analytics and reporting quality, as well as encounter reporting accuracy.

Key Services

• Develop and manage system configuration solutions
• Support the management of required system changes by line of business
• Configure associated business rules, benefit changes, and updates to codes, governmental policy, and provider data

Core System Transformation

Boost business performance by leveraging IT systems that ensure data security, scalability, and cost-effective operations. Clearlink collaborates with your team to build a roadmap that will turn risks into opportunities and improve operational efficiency, delivery consistency, system reliability, and organizational innovation.

Key Services

• Transform core systems to minimize your investment while maximizing efficiency
• Improve reliability through simplified architecture, optimized interfaces, and innovative assessments
• Streamline system process designs to promote scalability and integrate new LOBs
• Improve ability to leverage core system data actionable insights