*** Webcam interview*** long term project; initial PO for 1 year with multiyear extensions ***Remote***
Job Description
- Recommend and develop standards related to MCO oversight and monitoring
- Identify inefficiencies in the current MCO operations, including process mapping to identify gaps and redundancies
- Assist with drafting policy, contract amendments and other documents needed to support work ofThe client
- Recommend improvements and enhancements to MCO quality program, including Pay for Performance, Healthcare Effectiveness Data and Information Set (HEDIS), Performance Improvement Plans and more
- Recommend and support in the implementation of provider network adequacy approaches to helpThe client ensure access to care for members
- Develop recommendations and framework for operationalizing best practices related to claims analysis, reporting and other activities that will support and improve program integrity and overall program monitoring
Deliverable Description
Team of Experts: The Contractor will provide a qualified staff who are experts in Medicaid, MCO oversight, and have had experience in multiple states.
MCO Quality Strategy Plan: The Contractor will work with The client to develop effective MCO Quality Strategy Plans designed to meet KDHE-DHCF needs with the goal of improving the overall MCO quality program performance.
End-to-End Process Mapping Plan: The Contractor will work withThe client to analyze current state and determine efficiencies to provide an improved process map of the MCO operations that eliminates bottlenecks and inferior processes and creates innovative solutions for The client to implement. This will include but is not limited to process, system, reporting, and policy analysis.
MCO Oversight Plan: The Contractor will provide an MCO oversight and contract compliance plan. This will be based on a comprehensive review of clinical oversight and utilization management, utilizing best practices from other states.
Network Adequacy Determination: The Contractor will provide recommendations toThe client on updates and reporting recommendations for provider network counts and methods for determining network adequacy.
HEDIS Roadmap: The Contractor will provide a roadmap to assist The client in better utilizing Healthcare Effectiveness Data and Information Set (HEDIS) data. The roadmap will also inform The client how to structure reporting and oversight of HEDIS, including developing reporting that can be published on website to inform public on MCO performance in key areas.
Claim Analysis and Reporting Templates: The Contractor will provide claim analysis and reporting templates to be used by The client The intended result is the establishment of a clear and reliable documentation framework that enhances transparency, accountability, and measurement of program outcomes.
Analysis: The Contractor will provide expertise and support in using both quantitative analysis verses qualitative analysis to monitor MCO performance, clinical outcomes and more to support program operations.
Contractor Qualifications
- Expertise in MCO management, including but not limited to expertise in managed care regulations, managed care readiness review activities, and impact on state oversite
- Provider network analysis
- Dual-Eligibility Special Needs Plans (DSNP) expertise
- Third Party Liability (TPL) expertise
- Health Insurance Premium Payment
- Expertise in Medicaid and CHIP managed care regulations
- Expertise evaluating systems, including but not limited to information technology systems
- Proper licensure protocols
- Understanding of operational protocols
- Independence
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