Legacy to Leading Edge: Empowering Medicaid with Seamless Workflow Modernization 

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Overview

The state government sought to modernize four of its eleven Medicaid Home and Community-Based Services (HCBS) Waiver programs and improve tracking across various case management processes, including claims, complaints, appeals, prior authorizations, and more. They required workspace portals for case managers and case workers to support the multiple roles involved throughout the HCBS program lifecycle, from enrollment to disenrollment. These portals were designed to enable efficient management of diverse case types while adhering to established business processes.

Goal

The primary goal was to modernize four Medicaid Home and Community-Based Services (HCBS) Waiver programs, improve case management processes for handling diverse case types, and streamline eligibility determinations and service authorizations while providing real-time visibility into compliance and service delivery. Given the involvement of multiple agencies providing waiver services, the project also focused on generating detailed reports to support case managers and workers in maintaining effective communication within the system. Ultimately, the objective was to enhance access to essential Medicaid services for vulnerable populations across the state, ensuring they receive timely and efficient support.

Challenge

During the modernization of four Medicaid Home and Community-Based Services (HCBS) Waiver programs, several challenges were encountered, particularly in transitioning from the legacy system to the new platform. This process involved not only transferring data but also migrating attachments—a critical yet often-overlooked task—requiring meticulous planning to ensure seamless integration.

Additionally, integrating with multiple subsystems within the PRISM environment posed significant difficulties. Each subsystem had unique data requirements and protocols, which complicated the process of retrieving and synchronizing the necessary information. Addressing these complexities required extensive collaboration and rigorous testing to ensure accurate and efficient data flow across all systems.

Despite these hurdles, the team remained steadfast in delivering a robust solution that enhanced overall service delivery for the HCBS programs.

Solution

Sky Solutions designed a comprehensive solution featuring dedicated workspace portals for case managers and case workers, streamlining collaboration and processes from enrollment to disenrollment. These portals supported the diverse roles of providers and state government users, enabling efficient management of various case types in line with established business processes.

The solution enhanced tracking across multiple case management areas, including claims, complaints, appeals, prior authorizations, etc., while simplifying the prior authorization process within the HCBS programs. Recognizing the involvement of multiple agencies in providing waiver services, Sky Solutions developed detailed reports to aid case managers and workers in decision-making and communication.

Key highlights of the solution include:

  • Leveraging Pega to modernize four Medicaid Home and Community-Based Services (HCBS) Waiver programs
  • Implementing a centralized platform to streamline eligibility determinations, service authorizations, and case management
  • Creating dedicated workspace portals for providers and state government users to manage diverse case types effectively
  • Ensuring seamless integration with PRISM subsystems for real-time data access
  • Providing users with readily available, relevant information to improve efficiency
  • Incorporating robust tracking features to manage claims, complaints, appeals, etc.
  • Equipping case managers and workers with tools to enhance service delivery.

Technologies/Methodologies

  • Pega
  • FileNet
  • Low-Code/ No-Code

Outcome

Sky Solutions has streamlined the Medicaid prior authorization process, cutting delays and boosting efficiency for members and providers. Member enrollment now takes less than 30 days, down from 5-6 months. Providers can now add or update member services within hours instead of three months. State users and providers now have real-time access to track and update waiver program stages via user-friendly online portals.
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