Medicaid seen from every side
Most firms know one part of the Medicaid system. CalFina has worked in the state agency, in county health, and with the community organizations that deliver care, and that is the view this work needs.
Three vantage points
- The state
- Rajesh spent 13+ years inside California's Medicaid program, leading the largest Medicaid pharmacy transformation in US history, CMS certification of statewide systems, and the state's behavioral health claims system.
- The county
- Stabilizing a county CalAIM Justice-Involved program after go-live: claims, billing, EHR configuration, reporting, and the staff across custody, health, and managed care who have to work together.
- The community
- Lead consultant for community-based organizations (CBOs) preparing to deliver CalAIM Enhanced Care Management (ECM) and Community Supports (CS) to Medi-Cal members, through the Children and Families Coalition of Orange County technical assistance program. The work covers DHCS policy, managed care plan contracting, Domain 3 implementation, Medi-Cal compliance, and program design, and is delivered remotely.
Why it matters
A policy written at the state is carried out by counties, plans, and community organizations. Where those groups meet is where programs stall: a claim that does not match the rule, a service that cannot be billed, a report nobody can validate.
Having worked on each side, CalFina can read a problem from the rule down to the claim, and explain it to each group in terms it recognizes.
What that looks like in practice
- CBOs: ECM and Community Supports readiness, managed care contracting, Medi-Cal enrollment and billing compliance, and program design
- Counties: CalAIM implementation and post-go-live stabilization, claims and data quality
- State programs: project management, IV&V, and CMS certification
- Prime contractors: a small local partner with all three perspectives, plus Medicaid-experienced staff and workforce support