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Services | Health Plan – Operations Details


  • Process Remediation Support: BluePeak can provide subject matter expertise across all operational areas to enhance  compliance while improving operational efficiencies.  Whether issues were identified on audit, or internal monitoring, BluePeak can support appeals, grievances, organizational determinations, coverage determinations, enrollment, payment, call center, medical management, medication therapy management, DUR, clinical programs, Special Needs Plans (SNPs), formulary, provider relations or other operational areas in need of subject matter expertise and process remediation.  In addition, BluePeak can advise on organizational restructuring across all operational areas.
  • Operational gap analysis: BluePeak will provide an analysis of plan operations to identify gaps where the Medicare Advantage Plan’s Part D Sponsor’s or PBM’s are not meeting CMS regulations and guidelines.  We can do this across the plan or in specific areas where you think there may be issues.  We will then analyze the consistency across operational processes and written policies and procedures. BluePeak can assist plans with development of a database to demonstrate compliance with CMS regulations and guidelines or recommend online tools to support their businesses.
  • Vendor Oversight: CMS is turning their attention towards plans delegated vendors and how well  plans are overseeing and managing their vendors, paying particular attention to PBMs, clinical, medication therapy management (MTM) and enrollment vendors. BluePeak can review your vendor oversight programs, make suggestions for enhancements and assist with implementation of these new programs. BluePeak can also review your delegated vendors, and assist with operational assessments, vendor audits and ultimately new vendor RFPs if needed.
  • STAR Program Assistance: BluePeak can help you prioritize your resources to get the largest improvements for your dollar, as well as assist with project planning and strategies to enhance your Star ratings across all of your Part C and Part D measures.  We can share best practices across the 4 and 5 Star plans that make them successful.
  • Operational Interim Staffing: BluePeak can provide plan experienced subject matter experts to assist your staff on operational issues when you may need some extra support, or when you have had unexpected resignations.  Our team will also assist you with hiring the right people, with the right skill sets for your specific organization.
  • Staff Training: One of the most common issues within plans is lack of well-trained individuals that are performing critical daily operations. BluePeak will work with your staff and train them on specific operational processes on areas that may need some enhancement due to changes in guidance or staff turnover.  In some cases, processes have changed on paper, but staff may not have caught up to the new requirements.  BluePeak can help bridge those gaps.
  • Vendor RFP support: Not happy with your current downstream vendors? BluePeak can make recommendations for cost-effective, compliant vendors and provide support throughout the RFP process.

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