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HealthCare Business Process Outsourcing (BPO)

Medicaid BPO

A Blue Cross Blue Shield (BCBS) Medicaid plan contracted with a well-known business processing outsourcing vendor to transition Medicaid IT and business operations to the vendors’ platform. Initially the expectation was that the transition would be complete several months prior to the start of the new plan year and open enrollment period, giving both organizations time to adapt to the changes in responsibilities, new business processes, and to confirm and work through any anomalies encountered with the IT system. But, with the open enrollment period less than six months away, the transition to the vendor platform was substantially behind schedule and there was a serious concern that the deadline would not be met. If that occurred, financial penalties would be incurred by the State, the health plan, and by the outsourcing vendor.

Due to this high-level risk, the outsourcing vendor contracted with a senior ATIBA project manager to take over project responsibility to get the project back on track. Goals included meeting contract commitments so that financial penalties were not imposed and ensuring that the citizens of the State experienced a seamless transition from one plan year to another with no disruption of medical services resulting from the health plans’ business decision to move to an outsourced business model. Also of importance was the need to have all operations and IT functions in place to enable new membership and enrollment in the plan for the new plan year.

Project Scope

The project manager immediately performed an assessment on the health of the project, identified areas that needed immediate focus and triage, and got to work revising the project schedule and realigning resources. Risks were identified, and mitigation strategies were defined. Issues and defects were identified and prioritized, root cause analysis was conducted, and resolutions were implemented.

She worked tirelessly to build relationships with the numerous entities that comprised the project team, negotiated resource availability and deliverable dates to ensure the revised timeline could be met. She collaborated with the Medicaid Services team and senior management to interpret and validate contract requirements and developed an executive dashboard to communicate contract compliance.

Working with the functional SMEs, business, and operations team members, the PM gained a personal understanding of the Medicaid system solution as well as regulatory and operational requirements so that gaps and deficiencies could be more effectively identified and documented. She worked with the business and operations teams to develop new policies and procedures, and with the PBM vendor to ensure claims and enrollment information was correctly transmitted between the entities within the contractual service level agreements (SLAs). She worked to put a process in place so that emergency after hours communications could take place to ensure continuity of care.

The ATIBA project manager coordinated with all teams involved in this engagement (State, BCBS, PBM, business, operations, , IT, development, database, QA, enrollment & eligibility, fulfillment, EDI, billing, call center, reporting and analytics) to deliver end-to-end processes, procedures, and a comprehensive IT solution while ensuring clear ownership of roles and responsibilities across entities. The open enrollment date arrived, and all IT systems and Medicaid business operations were successfully transitioned to the outsourcing vendor with only minor issues encountered that were quickly resolved. Initial open enrollment resulted in the enrollment of over 50,000 Medicaid BCBS plan members, with over 120,000 members enrolled by the end of the open enrollment period.

Project Activities

  • Managed implementation, configuration and integration of all IT systems necessary to support the scope of Medicaid operations outsourced.
  • Implemented and validated all EDI file processing requirements, including membership enrollment and disenrollment.
  • Integrated pharmacy benefit manager (PBM) member validation and claims processing and implemented 24/7 hotline to resolve quality of care issues.
  • Re-engineered, streamlined and automated business and IT processes to obtain operational efficiencies.
  • Developed PCP auto assignment and member count ceilings to close the provider panel.
  • Developed routines to track copay max and out of pocket spend accumulations from multiple claims sources.
  • Integrated membership and claims data to downstream systems to support claims adjudication.
  • Ensured delivery of cohesive end-to-end process that included data interfaces with provider networks, prime pharmacy benefit manager and client data warehouse.

Industry: Healthcare
Category: Medicaid, BPO

  • Implemented FTP communication protocols for EPHI data exchanges.
  • Worked with fulfillment team to design and develop all Medicaid membership collateral, including post cards, welcome kit and insurance ID cards; obtained State and Medicaid Plan compliance sign off on all materials.
  • Managed development of system demo for State/CMS Readiness Review, ensuring all components functioned correctly and appropriate demo data was available.
  • Established SLAs for file processing and error reconciliation, established communication protocols for emergency, after-hours access, member verification exception procedures.
  • Integrated GPS processing so members could readily locate providers in-network nearest to their home.
  • Facilitated and managed requirements analysis, policies, procedures, risk management, issue management, system configuration, development, testing, system deployment and go-live cut-over.
  • Performed final PMO internal audit to ensure compliance with HIPAA data exchange standards, BCBS, State Medicaid and CMS regulatory and contract requirements.

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Lackawanna County
Elmhurst Township, PA 18444



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