CalFinaConsulting

Case studies

Three engagements, described at the program level. Client names are available on request.

A statewide Medicaid pharmacy transformation

The program
The largest Medicaid pharmacy transformation in US history: $17B in annual pharmacy spend and 18M+ beneficiaries.
The work
  • Built and governed delivery across 40+ concurrent projects and six portfolio teams.
  • Kept a 60 to 90 day resourcing outlook across a 600+ person vendor ecosystem: managed care plans, pharmacy benefit managers, counties, and safety net providers.
  • Standardized project tools, dashboards, and reporting cadences that stayed in place through the move to operations.
  • Briefed the agency CIO weekly on portfolio status, risk, financial performance, and vendor compliance.
  • Authored the annual Advance Planning Documents for the program.
The result
Zero application bugs in production at go-live. $300M+ in enhanced federal funding secured through CMS Streamlined Modular Certification.

Clearing a county's backlog of held Medicaid claims

The program
A county justice-involved Medicaid program with claims held in queue before reaching the state for reimbursement.
The work
  • Found that claims workflows had been configured incorrectly, so charges queued and held at several points between charging, billing, and claims.
  • Coordinated correctional facilities, county operations, pharmacy, public health, EHR analysts, county IT, and the state to clear the queues.
  • Found data quality problems and advised county leadership to treat all reporting as unvalidated until the data was confirmed.
  • Built the corrective action plan and the plan to move from backlog to stabilization.
The result
A stabilization plan, KPI dashboards, and recurring status reporting for county executives, and a county positioned for state audit readiness and future integration work.

CMS certification for two state platforms

The programs
A statewide provider enrollment platform and a state accounts receivable management platform.
The work
  • Benchmarked each system's capabilities against CMS certification standards, including the Medicaid Enterprise Certification Toolkit.
  • Owned milestone governance, compliance documentation, and executive reporting through go-live certification.
  • Negotiated milestones and briefed agency executives on status, risk, and audit findings.
The result
Directed both certifications through go-live. The provider enrollment certification secured $200M in enhanced federal funding over five years.

Working on a Medicaid or health IT program?

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