Operational/ Functional Area
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Scope
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Activities
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SME Resourcing Considerations
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Expected Deliverables
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Phase 2 Planning
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- Evaluation of opportunities
- Capture business requirements specifications to use for SOW
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- Perform SME interviews.
- Gap analysis (Enhancements coming out of testing)
- Perform impact analysis.
- Prioritization of proposed scope
- Governance development
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- Coordination with all teams during Phase 1. Capitalize on coordination of testing and improvement recommendations from team.
- Primary engagement with: Test Lead and Change Manager
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- Business case document
- Workflows & SOPs of Day 1 functionality
- Strategic Playbook
- Financial planning
- HR impacts (resulting from new tools and processes)
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Faxing Integration
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- API Integration for Inbound & Outbound
- Payer Authorization Portal Integrations
- Prior Auth & Decisioning Impact Evaluation
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- Document new API fax process E2E
- Work with Central IT Fax Services to capture Requirements.
- Draft funding request if required.
- Work with HC Enterprise Architect for County approval
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Coordination with HCIT Fax, HHIT, Rx, UM and Compliance
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- Workflow for API Implementation
- Support Documentation
- Test Cases
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Operational/ Functional Area
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Scope
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Activities
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SME Resourcing Considerations
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Expected Deliverables
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Case Management
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- Assessments
- Care plan development
- Care Giver Management
- Integration with Support Services
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- Work with Define requirements for Surveys & Assessments (~ 30)
- Advocacy Integration & Access to 3rd party tools to support services.
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Primary engagement with: CCM
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- Business Requirements for in-house development
- SOPs
- Workflows
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Finance (Risk Management)
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- CDPS to Support Finance Activities
- Evaluation of data driven care management activities in new system
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- Capture requirements for a Risk Management solution
- Document As Is workflow and integration with other processes.
- Evaluation of OOB reporting to determine improvement opportunities
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Primary engagement with: Finance
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Restricted Recipients
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- Improved DHS data integrations
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- Evaluation of process improvement activities to reduce manual touch-points.
- Review & refinement of processes with UM & Pop Health
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Primary Engagement: UM, Quality and Compliance
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- Updated process workflows
- BRD for Guidingcare changes & integration file requirements
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Transportation
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- Customer Care
- Transportation providers
- After Hours Authorization
- FACETS
- Reconciliation
- Compliance/Audit
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- Capture Improvement & Feature enhancements during testing
- Document reconciliation process for support, process improvement/automation
- Document Defect Management process (loss process)
- Develop SOPs for Customer Support
- Update Transportation provider communications
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Primary Engagement: Customer Care, Claims, Integrations
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- Updated workflows
- SOP for reconciliation process(es)
- Recommendations on automation processes to reduce losses
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FACETS/Authorization Optimization
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- Claims (Cognizant Collaboration)
- Customer Care
- Reconciliation
- Compliance/Audit
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- Collaboration with Cognizant on new Claims process project
- Document new workflow
- Capture requirements for changes to feeds, integration and cross-walks
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Primary Engagement: Integrations, Claims, IT
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- Requirements
- Test cases
- Workflows
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New Data Ingestion
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Primary Engagement: Quality, Pop Health, IT, Integrations
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Operational/ Functional Area
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Scope
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Activities
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SME Resourcing Considerations
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Expected Deliverables
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Quality Measures
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- HEDIS
- New Enrollee Programs
Expanding SNP activities and KPIs
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- Workflow optimization of Campaign Management activities
- Program Development documentation & Workflow
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Primary engagement with: Quality
Following critical compliance Black dates
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- SOPs
- Business Requirements for in-house development
- Identification of data needs & feeds
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Population Health
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- Work with data scientist to determine critical system data requirements.
- Capture Stakeholder impacts (support outreach/Quality and patient engagement activities)
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Engagement with the new Pop Health team (Director and data scientist)
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- Data source mapping documentation
- System requirements
- Business requirements
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Authorization Portal (Provider Access)
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- Interoperability
- Provider Engagement
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- Journey Mapping
- Interview HH leadership for goals & Objectives for solution
- Develop Business Requirements
- Survey Providers
- Identify integration touch-points
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Primary engagement: TBD, unclear who will own this new process
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- Advancing Interoperability Assessment (HL7 preparedness)
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Member Engagement Portal
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- Outreach management
- Content management
- Setup & Oversight
- Member enrollment integration
- Provider Visit tracking
- Field office visit tracking
- Material distribution
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- Define requirements & KPIs
- Administrative cost saving analysis
- Touch-point analysis (what operational areas will be impacted by the change, and have new processes)
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Primary Resource: Change Manager, Medical Administration, Campaign Management
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- Impact Analysis
- Business Objective Summary
- HR Hiring/restructuring considerations
- Performance KPIs
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