Case Study: Leading Healthcare Service Provider achieves CAQH CORE certification and launches Medicaid benefit with Optum

How one Payer Solved its Compliance Challenges

Leading Healthcare Service Provider, a small West Coast managed-care health plan, faced a high-profile, multi-departmental compliance challenge to achieve CAQH CORE Phase I–III certification within a tight nine-month window (with potential fines of $1.5M per year), while also needing a modern cloud-based ITMS, better provider data management, and an experienced IT project manager to launch a new Medicaid benefit. Optum provided a PMP-certified consultant and project management services and led the selection and rollout of Remedyforce as part of the solution.

Optum’s consultant led cross-functional teams to implement new EDI transactions, coordinate testing with CAQH, deploy Remedyforce enterprise-wide, build a provider network feeding multiple partners and a real-time web portal, and launch a coordinated Medicaid benefit. As a result, Optum delivered the compliance project on time and under budget—avoiding the $1.5M/year fines—completed more than ten projects over four years, and established regional provider data exchange standards and successful enterprise systems that improved reporting and operations.