Client Background

A start up Administrative Services Organization based in South Central USA. They are expanding their product line from Network Services to provide Health Plan services. They have a member base of 9000 members.

The ASO wanted to leverage Data as their differentiator and wanted to invest in building a mature Data Driven Organization.

Business Challenges:

The challenges faced were

  • Small IT team
  • Business team unable to define needs
  • Lack of documented processes and data sources
  • No confidence in data quality

The Executive team wanted a roadmap to disrupt the market, leveraging data as their asset to propel growth.

JBS Solutions

JBS was entrusted to define a roadmap for building Data Maturity in the organization and have a phased approach to prioritize the Data initiatives, streamline the processes and have a 99.99% data accuracy.

The first phase was building the Data Foundation. In this phase, JBS interviewed business owners for Contracting, Network Operations, Claims, HEOR, Plan Operations, Sales, Account Management and Executive team to build Process Maps, define various Data Sources and hand-offs between teams. Based on the above inputs, JBS created the Enterprise Data Model and created defined an Enterprise Business Glossary for effective communications. The Architecture for the EDW was defined and Data was ingested into Staging Area

The second phase started with Data Translation, converting all files into structured formats and loading it into the defined table structures. A parallel activity for Data Governance was initiated, two levels were setup: Data Governance Work Group and Data Governance Executive Council. All data related issues were discussed, business rules finalized in these two councils. Data Stewards for each area were identified and Exception reporting process was defined. Business Logic was created to identify, track and link different claims for members under a single Episode. As part of this phase, Claims Leakages to the tune of $550,000 were identified and handed over to the subrogation team.

The third phase was delivering Executive Dashboards and Customer Plan Performance Reports. The internal team was given visibility to Utilization Metrics to get business insights into High Cost Therapeutic areas and High Cost Claimants. Account Management team can download Plan Performance Reports and Metrics from internal portal and produce deliver reports to their respective accounts with 48 hours of month/quarter ending.

The fourth phase is being outlined to measure Provider Performance. All data related to Provider including Rate Sheets and Fee Schedules will be ingested. Provider Performance will be measured against Quality Measures as defined by the ASO and industry metrics. An Opportunity Assessment toolset will be created to improve productivity for responding to New Customer Acquisition process.