The Vendor is required to provide a consultant to develop a strategic plan and update tools for oversight and audits of delegated entities, and to ensure that oversight and audit efforts comply with relevant requirements.
- Provide health insurance programs for low-income children, adults, seniors and people with disabilities. it is county’s single largest health insurer, providing coverage through three major programs medical, state medicaid program for low-income children, adults, seniors, and people with disabilities; one care, which is a medicare advantage special needs plan for seniors and people with disabilities who qualify for both medicare and medical; and pace, program of all-inclusive care for the elderly, providing health and social services to frail older adults, so they can remain living in their communities.
- These providers perform utilization management, credentialing, claims payment, care management, and related services.
- Agency also contracts for other limited services such as credentialing, providing pharmacy benefits, and providing member transportation.
- Consulting services that will assess agency current delegated entity monitoring oversight and its annual audit processes, and will create or update tools, processes, and training to align with industry standard best practices and comply with requirements applicable.
- Delegation Oversight Audit Tools - assessment and revisions: conduct a gap analysis assessment of agency existing delegation oversight clinical and non-clinical annual audit tools (policy review tools & file review tools) to confirm that the tools capture the appropriate applicable regulatory and accreditation requirements and citations for each element and are within scope of the delegation agreement.
• Include a review of all audit elements, citations, possible evidence, and other components of each tool for each delegated functional area (um, claims, credentialing, sub delegation agreements, etc.);
• Work with agency to update the delegation oversight tools based on recommendations from the gap analysis.
- Alignment with internal audit: conduct a gap analysis assessment of agency delegation oversight tools and processes and agency internal audit tools and processes to identify gaps and potential areas for alignment between the two departments.
• Work with agency to update the delegation oversight tools and processes based on recommendations from the gap analysis.
• Develop a process for delegation oversight and internal audit to work together to foster alignment, share best practices, and increase efficiencies between the departments on an ongoing basis.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: April 30, 2025