PCP Attribution Operations
Teams Involved
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Member Services
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Provider Services
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Special Outreach
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Engineering/Configurable Design
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Legal
Project Type
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Strategic - New workflow for three teams
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Compliance - New market regulatory requirement
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Operational - Improvement of current escalation pathways for efficiency & effectiveness
Monday - Project Management
JIRA - Team escalation
Figma - Process Map
Google Sheets - Survey Logic
Campaign Builder - PCP Attribution campaign
Methodologies Used
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Lean Six Sigma
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Waterfall
Context
Member-initiated PCP Changes:
Members are initially assigned to a Primary Care Provider (PCP) based on their claims history or geographic location. Members have the flexibility to choose their PCP through their online/app profile or by contacting Member Services. When a member requests a PCP change, Member Services will inquire about the reason for the change to understand their needs and ensure a smooth transition.
PCP-initiated Panel Changes:
PCP's may also remove members from their panel under specific circumstances, such as non-compliance with treatment plans or disruptive behavior. In such cases, the PCP will notify the Provider Services team, who will escalate to the Special Outreach team. The Special Outreach team will then contact the member, assist them in finding an alternative PCP, and guide them through the process. Or, if the member is considered high-risk, such as those with chronic conditions or disabilities, the Special Outreach team will escalate a high-priority ticket to the Complex Case Management (CCM) team for further assistance.
This process prioritizes member choice and ensures a positive patient experience while maintaining a clear and efficient system for managing PCP assignments.
My Role
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Lead project manager
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Led the analysis of regulatory obligations for new HMO market entry, collaborating with the Legal team to ensure compliance.
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Identified and addressed inefficiencies in existing provider escalation processes. This included reviewing current JIRA field mapping and proposing a resolution to reduce secondary escalations.
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Developed a new escalation pathway for PCP attribution-related issues, including member complaints and fraud, waste, and abuse cases, and gained approval from key stakeholders, including team leaders and subject-matter experts.
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Collaborated with cross-functional teams: Worked with Special Outreach, Configurable Design, and Engineering teams to implement the new escalation process, including developing a campaign using the homegrown campaign system and ensuring accurate JIRA field mapping.
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Streamlined operational workflows: By implementing the new process and improving current escalation pathways, I improved efficiency and reduced resolution times for provider escalations, optimizing team resources and enhancing overall operational effectiveness.
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Deliverables
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End-to-end operations for Special Outreach, Member Services, and Provider Services teams with corresponding workflows published on Confluence
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Automated multi-outcome escalation survey that triggers provider outreach
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Campaign to reassign members when provider removes a patient from their pane
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Knowledge Management announcement to Member Services team
Overall Process
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Initiated process improvement by collaborating with the Legal team to understand regulatory obligations for the new HMO market.
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Conducted a thorough review of existing provider escalation processes, identifying inefficiencies in the current JIRA field mapping.
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Proposed and implemented a new escalation pathway for PCP attribution-related issues, addressing concerns like member complaints, fraud, waste, and abuse cases. This was achieved through close collaboration with the Provider Services team manager.
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Recognizing the limitations of existing tools, developed a new process utilizing a homegrown campaign system in conjunction with the Special Outreach team. This involved collaborating with the Configurable Design and Engineering teams to ensure seamless integration and accurate JIRA field mapping.
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Successfully implemented the updated escalation survey for the Member Services team, including thorough testing to ensure proper functionality and data accuracy.
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Documented the new process in Confluence for easy access and reference by the Provider Services, Member Services, and Special Outreach Teams.
Challenges & Learnings (What Went Wrong?)
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Challenge: Limited team capacities for the Engineering and Special Outreach teams.
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The Engineering team had competing priorities, impacting the initial project timeline.
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What I did: Proactively advocated for the importance of this project and negotiated a revised timeline while implementing interim processes to mitigate delays.
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The Special Outreach team manager expressed concerns about their capacity to handle a potential increase in ticket volume. .
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What I did: Presented an automated solution with an average task completion rate of 2 minutes and a low probability of team involvement (less than 10%), demonstrating the efficiency and scalability of the new process.
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Challenge: The automated escalation survey initially failed to populate information on the ticket subject line, hindering effective triaging within the Provider Services team.
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What I did: Promptly identified and resolved this issue by temporarily reverting to the original survey while coordinating with the Engineering team to implement the necessary updates.
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Results
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Successfully implemented the new escalation pathways, streamlining the processes, reducing resolution times by 15%, and ensuring regulatory compliance.
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Improved data accuracy and reduced manual effort by automating key aspects of the escalation process.