Информировать на e-mail
« Назад || Скачать / Открыть в формате Microsoft Word
Рисунок 1. Процессы верхнего уровня модели APQC Healthcare Insurance
Перечень процессов модели APQC Healthcare Insurance приведен ниже.
1.Develop Vision and Strategy
1.1.Define the business concept and long-term vision
1.1.1.Assess the external environment
1.1.1.1.Analyze and evaluate competition
1.1.1.2.Identify economic trends
1.1.1.3.Identify political and regulatory issues
1.1.1.4.Assess new technology innovations
1.1.1.5.Analyze demographics
1.1.1.6.Identify social and cultural changes
1.1.1.7.Identify ecological concerns
1.1.1.8.Identify health care insurance exchange level of participation and timing
1.1.2.Survey market and determine customer needs and wants
1.1.2.1.Conduct qualitative/quantitative assessments
1.1.2.2.Capture and assess customer needs
1.1.3.Perform internal analysis
1.1.3.1.Analyze organizational characteristics
1.1.3.2.Create baselines for current processes
1.1.3.3.Analyze systems and technology
1.1.3.4.Analyze financial positions
1.1.3.5.Identify enterprise core competencies
1.1.4.Establish strategic vision
1.1.4.1.Align stakeholders around strategic vision
1.1.4.2.Communicate strategic vision to stakeholders
1.2.Develop business strategy
1.2.1.Develop overall mission statement
1.2.1.1.Define current business
1.2.1.2.Formulate mission
1.2.1.3.Communicate mission
1.2.2.Evaluate strategic options to achieve the objectives
1.2.2.1.Define strategic options
1.2.2.2.Assess and analyze impact of each option
1.2.2.3.Develop sustainability strategy
1.2.2.4.Develop global support and shared services strategy
1.2.2.5.Develop lean/continuous improvement strategy
1.2.3.Conduct organization restructuring opportunities
1.2.3.1.Identify restructuring opportunities
1.2.3.2.Perform due-diligence
1.2.3.3.Analyze deal options
1.2.3.3.1.Evaluate acquisition options
1.2.3.3.2.Evaluate merger options
1.2.3.3.3.Evaluate de-merger options
1.2.3.3.4.Evaluate divesture options
1.2.4.Select long-term business strategy
1.2.5.Coordinate and align functional and process strategies
1.2.6.Create organizational design (structure, governance, reporting, etc.)
1.2.6.1.Evaluate breadth and depth of organizational structure
1.2.6.2.Perform job-specific roles mapping and value-added analyses
1.2.6.3.Develop role activity diagrams to assess hand-off activity
1.2.6.4.Perform organization redesign workshops
1.2.6.5.Design the relationships between organizational units
1.2.6.6.Develop role analysis and activity diagrams for key processes
1.2.6.7.Assess organizational implication of feasible alternatives
1.2.6.8.Migrate to new organization
1.2.7.Develop and set organizational goals
1.2.8.Formulate business unit strategies
1.3.Manage strategic initiatives
1.3.1.Develop strategic initiatives
1.3.2.Evaluate strategic initiatives
1.3.3.Select strategic initiatives
1.3.4.Establish high-level measures
2.Develop and Manage Products and Services
2.1.Manage product and service portfolio
2.1.1.Evaluate performance of existing products/services against market opportunities
2.1.2.Define product/service development requirements
2.1.2.1.Identify potential improvements to existing products and services
2.1.2.2.Identify potential new products and services
2.1.3.Perform discovery research
2.1.3.1.Identify new technologies
2.1.3.2.Develop new technologies
2.1.3.3.Assess feasibility of integrating new leading technologies into product/service concepts
2.1.4.Confirm alignment of product/service concepts with business strategy
2.1.4.1.Plan and develop cost and quality targets
2.1.4.2.Prioritize and select new product/service concepts
2.1.4.3.Specify development timing targets
2.1.4.4.Plan for product/service offering modifications
2.1.5.Manage product and service life cycle
2.1.5.1.Introduce new products/services
2.1.5.2.Retire outdated products/services
2.1.5.3.Identify and refine performance indicators
2.1.6.Manage product and service master data
2.2.Develop products and services
2.2.1.Design, build, and evaluate products and services
2.2.1.1.Assign resources to product/service project
2.2.1.2.Prepare high-level business case and technical assessment
2.2.1.3.Develop product/service design specifications
2.2.1.4.Document design specifications
2.2.1.5.Conduct mandatory and elective external reviews (legal, regulatory, standards, internal)
2.2.1.6.Build prototypes
2.2.1.7.Eliminate quality and reliability problems
2.2.1.8.Conduct in-house product/service testing and evaluate feasibility
2.2.1.9.Identify design/development performance indicators
2.2.1.10.Collaborate on design with suppliers and contract manufacturers
2.2.2.Test market for new or revised products and services
2.2.2.1.Prepare detailed market study
2.2.2.2.Conduct customer tests and interviews
2.2.2.3.Finalize product/service characteristics and business cases
2.2.2.4.Finalize technical requirements
2.2.2.5.Identify requirements for changes to manufacturing/delivery processes
2.2.3.Prepare for production
2.2.3.1.Develop and test prototype production and/or service delivery process
2.2.3.2.Design and obtain necessary materials and equipment
2.2.3.3.Install and validate production process or methodology
2.2.3.4.Monitor production runs
2.2.3.5.Request engineering change
2.2.3.6.Manage engineering change orders
3.Market and Sell Products and Services
3.1.Understand markets, customers, and capabilities
3.1.1.Perform customer and market intelligence analysis
3.1.1.1.Conduct customer and market research
3.1.1.2.Identify market segments
3.1.1.3.Analyze market and industry trends
3.1.1.4.Analyze competing organizations, competitive/substitute products
3.1.1.5.Evaluate existing products/brands
3.1.1.6.Assess internal and external business environment
3.1.2.Evaluate and prioritize market opportunities
3.1.2.1.Quantify market opportunities
3.1.2.2.Determine target segments
3.1.2.3.Prioritize opportunities consistent with capabilities and overall business strategy
3.1.2.4.Validate opportunities
3.2.Develop marketing strategy
3.2.1.Define offering and customer value proposition
3.2.1.1.Define offering and positioning
3.2.1.2.Develop value proposition including brand positioning for target segments
3.2.1.3.Validate value proposition with target segments
3.2.1.4.Develop new branding
3.2.2.Define pricing strategy to align to value proposition
3.2.2.1.Establish guidelines for applying pricing of products/services
3.2.2.2.Approve pricing strategies/policies
3.2.3.Define and manage channel strategy
3.2.3.1.Evaluate channel attributes and partners
3.2.3.2.Determine channel fit with target segments
3.2.3.3.Select channels for target segments
3.2.4.Design brochures/collateral
3.3.Develop sales strategy
3.3.1.Develop sales forecast
3.3.1.1.Gather current and historic order information
3.3.1.2.Analyze sales trends and patterns
3.3.1.3.Generate sales forecast
3.3.1.4.Analyze historical and planned promotions and events
3.3.2.Develop sales partner/alliance relationships
3.3.2.1.Identify alliance opportunities
3.3.2.2.Design alliance programs and methods for selecting and managing relationships
3.3.2.3.Select alliances
3.3.2.4.Develop partner and alliance management strategies
3.3.2.5.Establish partner and alliance management goals
3.3.3.Perform broker channel management
3.3.3.1.Profile brokers and agents
3.3.3.2.Contract with brokers and agents
3.3.4.Establish overall sales budgets
3.3.4.1.Calculate product revenue
3.3.4.2.Determine variable costs
3.3.4.3.Determine overhead and fixed costs
3.3.4.4.Calculate net profit
3.3.4.5.Create budget
3.3.5.Establish sales goals and measures
3.3.6.Establish customer management measures
3.4.Develop and manage marketing plans
3.4.1.Establish goals, objectives, and metrics for products by channels/segments
3.4.2.Establish marketing budgets
3.4.2.1.Confirm marketing alignment to business strategy
3.4.2.2.Determine costs of marketing
3.4.2.3.Create marketing budget
3.4.3.Develop and manage media
3.4.3.1.Define media objectives
3.4.3.2.Develop marketing messages
3.4.3.3.Define target audience
3.4.3.4.Engage media provider
3.4.3.5.Develop and execute advertising
3.4.3.6.Develop and execute other marketing campaigns/programs
3.4.3.7.Assess brand/product marketing plan performance
3.4.4.Develop and manage pricing
3.4.4.1.Determine pricing based on volume/unit forecast
3.4.4.2.Execute pricing plan
3.4.4.3.Evaluate pricing performance
3.4.4.4.Refine pricing as needed
3.5.Develop and manage sales plans
3.5.1.Manage sales collateral
3.5.1.1.Manage proposal templates
3.5.1.2.Develop and manage promotional activities
3.5.1.2.1.Define promotional concepts
3.5.1.2.2.Plan and test promotional activities
3.5.1.2.3.Execute promotional activities
3.5.1.2.4.Evaluate promotional performance metrics
3.5.1.2.5.Refine promotional performance metrics
3.5.1.2.6.Incorporate learning into future/planned consumer promotions
3.5.1.3.Track customer management measures
3.5.1.3.1.Determine customer loyalty/lifetime value
3.5.1.3.2.Analyze customer revenue trend
3.5.1.3.3.Analyze customer attrition and retention rates
3.5.1.3.4.Analyze customer metrics
3.5.1.3.5.Revise customer strategies, objectives, and plans based on metrics
3.5.1.3.6.Analyze purchasing behavior
3.5.1.3.7.Analyze customer campaigns
3.5.1.3.8.Analyze customer market research
3.5.1.4.Manage Campaigns
3.5.2.Develop and manage packaging strategy
3.5.2.1.Plan packaging strategy
3.5.2.2.Test packaging options
3.5.2.3.Execute packaging strategy
3.5.2.4.Refine packaging
3.6.Develop and manage sales plans
3.6.1.Generate leads
3.6.1.1.Identify potential customers
3.6.1.2.Identify leads
3.6.2.Manage customers and accounts
3.6.2.1.Develop sales/key account plan
3.6.2.2.Manage customer relationships
3.6.2.3.Manage customer master data
3.6.2.4.Premium payment profile administration
3.6.2.4.1.Set payment allocation
3.6.2.4.2.Manage responsible party
3.6.2.4.3.Assign billing attributes
3.6.2.4.4.Manage billing preferences
3.6.3.Manage customer sales
3.6.3.1.Conduct direct sales to groups
3.6.3.2.Perform sales calls
3.6.3.3.Perform pre-sales activities
3.6.3.3.1.Produce proposal
3.6.3.3.2.Produce renewals
3.6.3.3.3.Negotiate contracts
3.6.3.4.Close the sale
3.6.3.5.Record outcome of sales process
3.6.4.Manage sales orders
3.6.4.1.Accept and validate sales orders
3.6.4.2.Collect and maintain customer account information
3.6.4.3.Determine availability
3.6.4.4.Determine fulfillment process
3.6.4.5.Enter orders into system and identify/perform cross-sell/up-sell activity
3.6.4.6.Process back orders and updates
3.6.4.7.Handle order inquiries including post-order fulfillment transactions
3.6.5.Manage sales force
3.6.5.1.Determine sales resource allocation
3.6.5.2.Establish sales force incentive plan
3.6.6.Manage sales partners and alliances
3.6.6.1.Provide sales and product training to sales partners/alliances
3.6.6.2.Develop sales forecast by partner/alliance
3.6.6.3.Agree on partner and alliance commissions
3.6.6.4.Evaluate partner/alliance results
3.6.6.5.Manage channel partner master data
3.6.6.6.Manage distribution channels
3.7.Enroll and onboard membership
3.7.1.Validate members
3.7.1.1.Conduct CMS authorization
3.7.1.2.Verify member information
3.7.1.3.Determine enrollment eligibility
3.7.2.Profile members
3.7.2.1.Create and/or modify manage member identifier number
3.7.2.2.Input or update member demographics
3.7.2.3.Input or update confidential communication profile
3.7.2.4.Input or update ember provider panel/PCP
3.7.2.5.Manage coverage enrollments
3.7.2.6.Collect associate member healthcare information
3.7.2.7.Coordinate benefits
3.7.3.Conduct fulfillment administration
3.7.3.1.Specify appropriate member welcome Letters
3.7.3.2.Specify ID Card Template
3.7.3.3.Specify Benefit Booklet
3.7.4.Install and maintain account/case
3.7.4.1.Set up account structure and maintenance
3.7.4.2.Manage group demographics
3.7.4.3.Manage group contacts
3.7.4.4.Verify group information
3.7.4.5.Verify group participation requirements
3.7.4.6.Manage rate schedules
3.8.Perform policy renewal and maintenance
3.8.1.Generate pre-renewal material (advance notice of change)
3.8.2.Conduct early renewal process
3.8.3.Conduct annual renewal process
3.8.4.Conduct late renewal process
4.Deliver Products and Services
4.1.Plan for and align supply chain resources
4.1.1.Develop production and materials strategies
4.1.1.1.Define manufacturing goals
4.1.1.2.Define labor and materials policies
4.1.1.3.Define outsourcing policies
4.1.1.4.Define manufacturing capital expense policies
4.1.1.5.Define capacities
4.1.1.6.Define production network and supply constraints
4.1.1.7.Define production process
4.1.1.8.Define production workplace layout and infrastructure
4.1.2.Manage demand for products and services
4.1.2.1.Develop baseline forecasts
4.1.2.2.Collaborate with customers
4.1.2.3.Develop consensus forecast
4.1.2.4.Determine available to promise
4.1.2.5.Monitor activity against forecast and revise forecast
4.1.2.6.Evaluate and revise forecasting approach
4.1.2.7.Measure forecast accuracy
4.1.3.Create materials plan
4.1.3.1.Create unconstrained plan
4.1.3.2.Collaborate with supplier and contract manufacturers
4.1.3.3.Identify critical materials and supplier capacity
4.1.3.4.Monitor material specifications
4.1.3.5.Generate constrained plan
4.1.3.6.Define production balance and control
4.1.4.Create and manage master production schedule
4.1.4.1.Create site-level production plan and schedule
4.1.4.2.Manage work-in-progress inventory
4.1.4.3.Collaborate with suppliers
4.1.4.4.Execute site-level production plan and schedule
4.1.4.5.Monitor master production schedule and plan
4.1.5.Plan distribution requirements
4.1.5.1.Maintain master data
4.1.5.2.Determine finished goods inventory requirements at destination
4.1.5.3.Calculate requirements at destination
4.1.5.4.Calculate consolidation at source
4.1.5.5.Manage collaborative replenishment planning
4.1.5.6.Manage requirements for partners
4.1.5.7.Calculate destination dispatch plan
4.1.5.8.Manage dispatch plan attainment
4.1.5.9.Calculate destination load plans
4.1.5.10.Manage partner load plan
4.1.5.11.Manage cost of supply
4.1.5.12.Manage capacity utilization
4.1.6.Establish distribution planning constraints
4.1.6.1.Establish distribution center layout constraints
4.1.6.2.Establish inventory management constraints
4.1.6.3.Establish transportation management constraints
4.1.7.Review distribution planning policies
4.1.7.1.Review distribution network
4.1.7.2.Establish sourcing relationships
4.1.7.3.Establish dynamic deployment policies
4.1.8.Assess distribution planning performance
4.1.8.1.Establish appropriate performance indicators (metrics)
4.1.8.2.Establish monitoring frequency
4.1.8.3.Calculate performance measures
4.1.8.4.Identify performance trends
4.1.8.5.Analyze performance benchmark gaps
4.1.8.6.Prepare appropriate reports
4.1.8.7.Develop performance improvement plan
4.1.9.Develop quality standards and procedures
4.1.9.1.Establish quality targets
4.1.9.2.Develop standard testing procedures
4.1.9.3.Communicate quality specifications
4.2.Manage health care delivery
4.2.1.Generate medical informatics
4.2.1.1.Perform existing network analysis
4.2.1.2.Perform gap in care analysis
4.2.1.3.Perform service and procedure analysis
4.2.2.Perform health program management
4.2.2.1.Manage health programs
4.2.2.2.Develop health management programs
4.2.2.3.Manage health program enrollment
4.2.2.4.Perform health program analytics
4.2.2.5.Deliver health programs
4.2.3.Perform medical policy management
4.2.3.1.Develop medical policy rules
4.2.3.2.Monitor medical policy
4.2.3.3.Review medical policy appeal
4.2.4.Perform utilization management
4.2.4.1.Manage prior-authorizations/pre-certify
4.2.4.2.Manage provider referral
4.2.4.3.Enforce medical policy
4.3.Support healthcare management
4.3.1.Develop healthcare management policy, planning, and strategy
4.3.1.1.Develop and maintain contracting and reimbursement policies
4.3.1.2.Develop and maintain medical policies
4.3.1.3.Develop and maintain network strategy and plan
4.3.1.4.Develop contracting standards
4.3.1.5.Manage contract templates
4.3.1.6.Build and maintain standard fee schedules
4.3.1.7.Manage provider rate sheets
4.3.2.Develop and manage the network
4.3.2.1.Identify and recruit providers
4.3.2.2.Credential and re-credential providers
4.3.2.3.Negotiate and contract with providers
4.3.2.4.Profile providers
4.3.2.5.Manage provider practice/group arrangements
4.3.2.6.Assemble provider market intelligence
4.3.2.7.Assemble provider performance indicators
4.3.2.8.Manage and monitor providers
4.3.2.9.Manage revenue cycle
4.3.2.10.Develop provider communications
4.3.2.11.Educate and train providers
4.3.2.12.Maintain provider data and directories
4.3.2.13.Manage quality and performance of the network management process
4.3.2.14.Manage ancillary services
4.3.2.15.Manage lab services
4.3.2.16.Manage other ancillary services
4.3.3.Perform pre-pay provider reimbursement
4.3.3.1.Process encounter information
4.3.3.2.Process capitation reimbursement
4.3.3.3.Process and reconcile specialized reimbursements
4.3.4.Perform medical management
4.3.4.1.Conduct utilization management
4.3.4.2.Perform case management and disease management with members
4.3.4.3.Perform referral management for members
4.3.4.4.Promote wellness and patient education
4.3.5.Manage service provider relationships
4.3.5.1.Manage provider relationships and loyalty
4.3.5.2.Manage provider inquiry intake
4.3.5.3.Perform research and resolve inquiries
4.3.5.4.Provide orientation, education, and feedback to providers
4.3.6.Conduct provider performance management
4.3.6.1.Coach and train providers
4.3.6.2.Terminate Provider contracts
4.3.6.3.Manage Provider service quality
4.3.7.Communicate with providers
4.3.7.1.Manage provider communication campaigns
4.3.7.2.Manage provider requests
4.3.8.Conduct pharmacy benefit management
4.3.8.1.Review member drug utilization
4.3.8.2.Manage drug Formulary
4.3.8.3.Negotiate formulary rebate
4.3.8.4.Perform Mail order pharmacy with members
4.4.Adjudicate claims and process reimbursement
4.4.1.Develop claim/encounter informatics
4.4.1.1.Manage and report on claim processing activity
4.4.1.2.Manage quality assurance and auditing procedures
4.4.1.3.Manage critical inquiry process and appeals
4.4.2.Adjudicate claims
4.4.2.1.Determine coverage/benefits
4.4.2.2.Perform clinical editing
4.4.2.3.Determine covered service
4.4.2.4.Determine eligibility
4.4.3.Process intake of claims
4.4.3.1.Enter paper claims into claims system
4.4.3.2.Enter OCR claims into claims system
4.4.3.3.Enter electronic claims into claims system
4.4.3.4.Enter interactive claims into claims system
4.4.3.5.Create claims imaging and record within claims system
4.4.3.6.Assign claim control ID
4.4.3.7.Route claims for processing
4.4.3.8.Conduct pre-edit claims examination
4.4.3.9.Validate claims
4.4.4.Perform claim policy management
4.4.4.1.Develop claim policy rules
4.4.4.2.Monitor claim policy
4.4.4.3.Review claim policy appeal
4.4.5.Communicate claim outcomes
4.4.5.1.Generate remittance advise
4.4.5.2.Generate explanation of benefits
4.4.6.Perform benefits management
4.4.6.1.Provide benefits support
4.4.6.2.Provide benefits administration
4.4.7.Prepare and process claims
4.4.8.Process reimbursement and notification
4.4.9.Manage other party liabilities
4.5.Manage receipt and route of transactions
4.5.1.Process web-based transactions
4.5.2.Process electronic data interchange (EDI) transactions
4.5.3.Process paper transactions (mail room)
4.6.Provide explanation of benefits to members
4.7.Procure materials and services
4.7.1.Develop sourcing strategies
4.7.1.1.Develop procurement plan
4.7.1.2.Clarify purchasing requirements
4.7.1.3.Develop inventory strategy
4.7.1.4.Match needs to supply capabilities
4.7.1.5.Analyze organization’s spend profile
4.7.1.6.Seek opportunities to improve efficiency and value
4.7.1.7.Collaborate with suppliers to identify sourcing opportunities
4.7.2.Select suppliers and develop/maintain contracts
4.7.2.1.Select suppliers
4.7.2.2.Certify and validate suppliers
4.7.2.3.Negotiate and establish contracts
4.7.2.4.Manage contracts
4.7.3.Order materials and services
4.7.3.1.Process/Review requisitions
4.7.3.2.Approve requisitions
4.7.3.3.Solicit/Track vendor quotes
4.7.3.4.Create/Distribute purchase orders
4.7.3.5.Expedite orders and satisfy inquiries
4.7.3.6.Record receipt of goods
4.7.3.7.Research/Resolve exceptions
4.7.4.Manage suppliers
4.7.4.1.Monitor/Manage supplier information
4.7.4.2.Prepare/Analyze procurement and vendor performance
4.7.4.3.Support inventory and production processes
4.7.4.4.Monitor quality of product delivered
4.8.Produce/Manufacture/Deliver product
4.8.1.Schedule production
4.8.1.1.Generate line level plan
4.8.1.2.Generate detailed schedule
4.8.1.3.Schedule production orders and create lots
4.8.1.4.Schedule preventive (planned) maintenance (preventive maintenance orders)
4.8.1.5.Schedule requested (unplanned) maintenance (work order cycle)
4.8.1.6.Release production orders and create lots
4.8.2.Produce product
4.8.2.1.Manage raw material inventory
4.8.2.2.Execute detailed line schedule
4.8.2.3.Report maintenance issues
4.8.2.4.Rerun defective items
4.8.2.5.Assess production performance
4.8.3.Perform quality testing
4.8.3.1.Calibrate test equipment
4.8.3.2.Perform testing using the standard testing procedure
4.8.3.3.Record test results
4.8.4.Maintain production records and manage lot traceability
4.8.4.1.Determine lot numbering system
4.8.4.2.Determine lot use
4.9.Deliver service to customer
4.9.1.Confirm specific service requirements for individual customer
4.9.1.1.Process customer request
4.9.1.2.Create customer profile
4.9.1.3.Generate service order
4.9.2.Identify and schedule resources to meet service requirements
4.9.2.1.Create resourcing plan and schedule
4.9.2.2.Create service order fulfillment schedule
4.9.2.3.Develop service order
4.9.3.Provide service to specific customers
4.9.3.1.Organize daily service order fulfillment schedule
4.9.3.2.Dispatch resources
4.9.3.3.Manage order fulfillment progress
4.9.3.4.Validate order fulfillment block completion
4.9.4.Ensure quality of service
4.9.4.1.Identify completed orders for feedback
4.9.4.2.Identify incomplete orders and service failures
4.9.4.3.Solicit customer feedback on services delivered
4.9.4.4.Process customer feedback on services delivered
4.10.Manage logistics and warehousing
4.10.1.Define logistics strategy
4.10.1.1.Translate customer service requirements into logistics requirements
4.10.1.2.Design logistics network
4.10.1.3.Communicate outsourcing needs
4.10.1.4.Develop and maintain delivery service policy
4.10.1.5.Optimize transportation schedules and costs
4.10.1.6.Define key performance measures
4.10.2.Plan and manage inbound material flow
4.10.2.1.Plan inbound material receipts
4.10.2.2.Manage inbound material flow
4.10.2.3.Monitor inbound delivery performance
4.10.2.4.Manage flow of returned products
4.10.3.Operate warehousing
4.10.3.1.Track inventory deployment
4.10.3.2.Receive, inspect, and store inbound deliveries
4.10.3.3.Track product availability
4.10.3.4.Pick, pack, and ship product for delivery
4.10.3.5.Track inventory accuracy
4.10.3.6.Track third-party logistics storage and shipping performance
4.10.3.7.Manage physical finished goods inventory
4.10.4.Operate outbound transportation
4.10.4.1.Plan, transport, and deliver outbound product
4.10.4.2.Track carrier delivery performance
4.10.4.3.Manage transportation fleet
4.10.4.4.Process and audit carrier invoices and documents
4.10.5.Manage returns; manage reverse logistics
4.10.5.1.Authorize and process returns
4.10.5.2.Perform reverse logistics
4.10.5.3.Perform salvage activities
4.10.5.4.Manage and process warranty claims
4.10.5.5.Manage repair/refurbishment and return to customer/stock
5.Manage Customer Service
5.1.Develop customer care/customer service strategy
5.1.1.Develop customer service segmentation/prioritization (e.g., tiers)
5.1.1.1.Analyze existing customers
5.1.1.2.Analyze feedback of customer needs
5.1.2.Define customer service policies and procedures
5.1.3.Establish service levels for customers
5.1.4.Manage service protocols
5.1.4.1.Develop service policies and procedures
5.1.4.2.Manage service routing and workflow
5.1.4.3.Manage documented service level agreements
5.2.Plan and manage customer service operations
5.2.1.Plan and manage customer service work force
5.2.1.1.Forecast volume of customer service contacts
5.2.1.2.Schedule customer service work force
5.2.1.3.Track work force utilization
5.2.1.4.Monitor and evaluate quality of customer interactions with customer service representatives
5.2.2.Manage customer service requests/inquiries
5.2.2.1.Receive customer requests/inquiries
5.2.2.2.Route customer requests/inquiries
5.2.2.3.Respond to customer requests/inquiries
5.2.3.Manage customer complaints
5.2.3.1.Receive customer complaints
5.2.3.2.Route customer complaints
5.2.3.3.Resolve customer complaints
5.2.3.4.Respond to customer complaints
5.2.4.Conduct correspondence management
5.2.4.1.Track correspondence to case
5.2.4.2.Retrieve correspondence image upon request
5.2.5.Perform member outreach
5.2.5.1.Plan product information
5.2.5.2.Provide wellness information to members
5.2.6.Manage appeals and grievances
5.2.6.1.Receive provider claims grievances
5.2.6.2.Conduct provider claims appeals process
5.2.6.3.Receive member service grievances
5.2.6.4.Conduct customer service grievances process
5.2.7.Perform membership inquiry/eligibility and coverage procedures
5.2.8.Perform billing and payment support processes
5.2.8.1.Request invoice by member
5.2.8.2.Update billing and payment profile
5.2.8.3.Request payment status by member
5.2.8.4.Send payment reminder to member
5.2.9.Maintain nurse line help desk
5.2.9.1.Provide wellness support to members
5.2.9.2.Supply pre-PCP visit support
5.2.10.Perform service analytics
5.3.Manage customer relationships and billing
5.3.1.Create account paperwork
5.3.2.Manage account relationships
5.3.3.Account member setup and maintenance
5.3.3.1.Manage account and member setup
5.4.Maintain member relationships and inquires
5.4.1.Manage member relationships and loyalty
5.4.2.Manage member inquiry intake
5.4.3.Perform research and resolve inquiries
5.4.4.Perform tracking, follow-up, and reporting
5.5.Measure and evaluate customer service operations
5.5.1.Measure customer satisfaction with customer requests/inquiries handling
5.5.1.1.Gather and solicit post-sale customer feedback on products and services
5.5.1.2.Solicit post-sale customer feedback on ad effectiveness
5.5.1.3.Analyze product and service satisfaction data and identify improvement opportunities
5.5.1.4.Provide customer feedback to product management on products and services
5.5.2.Measure customer satisfaction with customer-complaint handling and resolution
5.5.2.1.Solicit customer feedback on complaint handling and resolution
5.5.2.2.Analyze customer complaint data and identify improvement opportunities
5.5.3.Measure customer satisfaction with products and services
5.5.3.1.Gather and solicit post-sale customer feedback on products and services
5.5.3.2.Solicit post-sale customer feedback on ad effectiveness
5.5.3.3.Analyze product and service satisfaction data and identify improvement opportunities
5.5.3.4.Provide customer feedback to product management on products and services
6.Develop and Manage Human Capital
6.1.Develop and manage human resources (HR) planning, policies, and strategies
6.1.1.Develop human resources strategy
6.1.1.1.Identify strategic HR needs
6.1.1.2.Define HR and business function roles and accountability
6.1.1.3.Determine HR costs
6.1.1.4.Establish HR measures
6.1.1.5.Communicate HR strategies
6.1.1.6.Develop strategy for HR systems/technologies/tools
6.1.2.Develop and implement workforce strategy and policies
6.1.2.1.Gather skill requirements according to corporate strategy and market environment
6.1.2.2.Plan employee resourcing requirements per unit/organization
6.1.2.3.Develop compensation plan
6.1.2.4.Develop succession plan
6.1.2.5.Develop employee diversity plan
6.1.2.6.Develop other HR programs
6.1.2.7.Develop HR policies
6.1.2.8.Administer HR policies
6.1.2.9.Plan employee benefits
6.1.2.10.Develop work force strategy models
6.1.3.Monitor and update strategy, plans, and policies
6.1.3.1.Measure realization of objectives
6.1.3.2.Measure contribution to business strategy
6.1.3.3.Communicate plans and provide updates to stakeholders
6.1.3.4.Determine value added from HR function
6.1.3.5.Review and revise HR plans
6.1.4.Develop competency management models
6.2.Recruit, source, and select employees
6.2.1.Manage employee requisitions
6.2.1.1.Align staffing plan to work force plan and business unit strategies/resource needs
6.2.1.2.Develop and open job requisitions
6.2.1.3.Develop job descriptions
6.2.1.4.Post requisitions
6.2.1.5.Manage internal/external job posting Web sites
6.2.1.6.Modify requisitions
6.2.1.7.Notify hiring manager
6.2.1.8.Manage requisition dates
6.2.2.Recruit/Source candidates
6.2.2.1.Determine recruitment methods and channels
6.2.2.2.Perform recruiting activities/events
6.2.2.3.Manage recruitment vendors
6.2.2.4.Manage employee referral programs
6.2.2.5.Manage recruitment channels
6.2.3.Screen and select candidates
6.2.3.1.Identify and deploy candidate selection tools
6.2.3.2.Interview candidates
6.2.3.3.Test candidates
6.2.3.4.Select and reject candidates
6.2.4.Manage pre-placement verification
6.2.4.1.Obtain candidate background information
6.2.4.2.Conduct pre-employment screening
6.2.4.3.Recommend/not recommend candidate
6.2.5.Manage new hire/re-hire
6.2.5.1.Draw up and make offer
6.2.5.2.Negotiate offer
6.2.5.3.Hire candidate
6.2.6.Manage Applicant Information
6.2.6.1.Create applicant record
6.2.6.2.Manage/Track applicant data
6.2.6.3.Archive and retain records of non-hires
6.3.Develop and counsel employees
6.3.1.Manage employee orientation and deployment
6.3.1.1.Create/Maintain employee on-boarding program
6.3.1.2.Introduce new employees to managers
6.3.1.3.Introduce workplace
6.3.1.4.Evaluate the effectiveness of employee on-boarding program
6.3.1.5.Execute onboarding program
6.3.2.Manage employee performance
6.3.2.1.Define performance objectives
6.3.2.2.Review, appraise, and manage employee performance
6.3.2.3.Evaluate and review performance program
6.3.3.Manage employee development
6.3.3.1.Develop competency management plans
6.3.3.2.Define employee development guidelines
6.3.3.3.Develop employee career plans
6.3.3.4.Manage employee skills development
6.3.4.Develop and train employees
6.3.4.1.Align employee and organization development needs
6.3.4.2.Align learning programs with competencies
6.3.4.3.Establish training needs by analysis of required and available skills
6.3.4.4.Develop, conduct, and manage employee and/or management training programs
6.4.Manage employee relations
6.4.1.Manage health and safety
6.4.2.Manage labor relations
6.4.3.Manage collective bargaining process
6.4.4.Manage labor management partnerships
6.4.5.Manage employee grievances
6.5.Reward and retain employees
6.5.1.Develop and manage reward, recognition, and motivation programs
6.5.1.1.Develop salary/compensation structure and plan
6.5.1.2.Develop benefits and reward plan
6.5.1.3.Perform competitive analysis of benefit and rewards
6.5.1.4.Identify compensation requirements based on financial, benefits, and HR policies
6.5.1.5.Administer compensation and rewards to employees
6.5.1.6.Reward and motivate employees
6.5.1.7.Deliver programs to support work/life balance for employees
6.5.2.Manage and administer benefits
6.5.2.1.Deliver employee benefits program
6.5.2.2.Administer benefit enrollment
6.5.2.3.Process claims
6.5.2.4.Perform benefit reconciliation
6.5.3.Manage employee assistance and retention
6.5.3.1.Develop family support systems
6.5.3.2.Review retention and motivation indicators
6.5.3.3.Review compensation plan
6.5.4.Administer payroll
6.6.Redeploy and retire employees
6.6.1.Manage promotion and demotion process
6.6.2.Manage separation
6.6.3.Manage retirement
6.6.4.Manage leave of absence
6.6.5.Develop and implement employee outplacement
6.6.6.Manage deployment of personnel
6.6.7.Relocate employees, and manage assignments
6.6.8.Manage expatriates
6.7.Manage employee information and analytics
6.7.1.Manage reporting processes
6.7.2.Manage employee inquiry process
6.7.3.Manage and maintain employee data
6.7.4.Manage human resource information systems (HRIS)
6.7.5.Develop and manage employee metrics
6.7.6.Develop and manage time and attendance systems
6.7.7.Manage employee communication
6.7.7.1.Develop employee communication plan
6.7.7.2.Manage/Collect employee suggestions and perform employee research
6.7.7.3.Deliver employee communications
7.Manage Information Technology
7.1.Manage the business of information technology
7.1.1.Develop the enterprise IT strategy
7.1.1.1.Build strategic intelligence
7.1.1.2.Identify long-term IT needs of the enterprise in collaboration with stakeholders
7.1.1.3.Define strategic standards, guidelines, and principles
7.1.1.4.Define and establish IT architecture and development standards
7.1.1.5.Define strategic vendors for IT components
7.1.1.6.Establish IT governance organization and processes
7.1.1.7.Build strategic plan to support business objectives
7.1.2.Define the enterprise architecture
7.1.2.1.Establish the enterprise architecture definition
7.1.2.2.Confirm enterprise architecture maintenance approach
7.1.2.3.Maintain the relevance of the enterprise architecture
7.1.2.4.Act as clearinghouse for IT research and innovation
7.1.2.5.Govern the enterprise architecture
7.1.3.Manage the IT portfolio
7.1.3.1.Establish the IT portfolio
7.1.3.2.Analyze and evaluate the value of the IT portfolio for the enterprise
7.1.3.3.Provision resources in accordance with strategic priorities
7.1.4.Perform IT research and innovation
7.1.4.1.Research technologies to innovate IT services and solutions
7.1.4.2.Transition viable technologies for IT services and solutions development
7.1.5.Evaluate and communicate IT business value and performance
7.1.5.1.Establish and monitor key performance indicators
7.1.5.2.Evaluate IT plan performance
7.1.5.3.Communicate IT value
7.2.Develop and manage IT customer relationships
7.2.1.Develop IT services and solutions strategy
7.2.1.1.Research IT services and solutions to address business and user requirements
7.2.1.2.Translate business and user requirements into IT services and solutions requirements
7.2.1.3.Formulate IT services and solutions strategic initiatives
7.2.1.4.Coordinate strategies with internal stakeholders to ensure alignment
7.2.1.5.Evaluate and select IT services and solutions strategic initiatives
7.2.2.Develop and manage IT service levels
7.2.2.1.Create and maintain the IT services and solutions catalog
7.2.2.2.Establish and maintain business and IT service-level agreements
7.2.2.3.Evaluate and report service-level attainment results
7.2.2.4.Communicate business and IT service-level improvement opportunities
7.2.3.Perform demand-side management (DSM) for IT services
7.2.3.1.Analyze IT services and solutions consumption and usage
7.2.3.2.Develop and implement incentive programs that improve consumption efficiency
7.2.3.3.Develop volume/unit forecast for IT services and solutions
7.2.4.Manage IT customer satisfaction
7.2.4.1.Capture and analyze customer satisfaction
7.2.4.2.Assess and communicate customer satisfaction patterns
7.2.4.3.Initiate improvements based on customer satisfaction patterns
7.2.5.Market IT services and solutions
7.2.5.1.Develop IT services and solutions marketing strategy
7.2.5.2.Develop and manage IT customer strategy
7.2.5.3.Manage IT services and solutions advertising and promotional campaigns
7.2.5.4.Process and track IT services and solutions orders
7.3.Develop and implement security, privacy, and data protection controls
7.3.1.Establish information security, privacy, and data protection strategies and levels
7.3.2.Test, evaluate, and implement information security and privacy and data protection controls
7.4.Manage enterprise information
7.4.1.Perform EDI Management
7.4.1.1.Send HIPAA Updates
7.4.1.2.Communicate with clearing houses
7.4.1.3.Send HIE updates
7.4.1.4.Update platforms
7.4.2.Perform provider informatics
7.4.2.1.Model provider contracts
7.4.2.2.Assess provider/vendor performance
7.4.2.3.Perform provider quality analysis
7.4.2.4.Identify provider trends
7.4.2.5.Assess provider reporting standards
7.4.3.Develop and maintain product informatics/reporting
7.4.3.1.Develop product performance quality analysis
7.4.3.2.Develop product utilization analysis
7.4.3.3.Develop product economics
7.4.3.4.Develop product demographics
7.4.3.5.Develop product portfolio distributions/contributions
7.4.3.6.Develop product risk indexes
7.4.4.Perform membership analytics
7.4.4.1.Perform membership stratification
7.4.4.2.Perform membership analytics
7.4.5.Set up membership accounts analytics
7.4.5.1.Perform service metrics analysis
7.4.5.2.Develop internal process metric analysis
7.4.6.Develop information and content management strategies
7.4.6.1.Understand information and content management needs and the role of IT services for executing the business strategy
7.4.6.2.Assess the information and content management implications of new technologies
7.4.6.3.Identify and prioritize information and content management actions
7.4.7.Define the enterprise information architecture
7.4.7.1.Define information elements, composite structure, logical relationships and constraints, taxonomy, and derivation rules
7.4.7.2.Define information access requirements
7.4.7.3.Establish data custodianship
7.4.7.4.Manage changes to content data architecture requirements
7.4.8.Manage information resources
7.4.8.1.Define the enterprise information/data policies and standards
7.4.8.2.Develop and implement data and content administration
7.4.9.Perform enterprise data and content management
7.4.9.1.Define sources and destinations of content data
7.4.9.2.Manage technical interfaces to users of content
7.4.9.3.Manage retention, revision, and retirement of enterprise information
7.5.Develop and maintain information technology solutions
7.5.1.Develop the IT development strategy
7.5.1.1.Establish sourcing strategy for IT development
7.5.1.2.Define development processes, methodologies, and tools standards
7.5.1.3.Select development methodologies and tools
7.5.2.Perform IT services and solutions life cycle planning
7.5.2.1.Plan development of new requirements
7.5.2.2.Plan development of feature and functionality enhancement
7.5.2.3.Develop life cycle plan for IT services and solutions
7.5.3.Develop and maintain IT services and solutions architecture
7.5.3.1.Create IT services and solutions architecture
7.5.3.2.Revise IT services and solutions architecture
7.5.3.3.Retire IT services and solutions architecture
7.5.4.Create IT services and solutions
7.5.4.1.Understand confirmed requirements
7.5.4.2.Design IT services and solutions
7.5.4.3.Acquire/Develop IT service/solution components
7.5.4.4.Train services and solutions resources
7.5.4.5.Test IT services/solutions
7.5.4.6.Confirm customer acceptance
7.5.5.Maintain IT services and solutions
7.5.5.1.Understand upkeep/enhance requirements and defect analysis
7.5.5.2.Design change to existing IT service/solution
7.5.5.3.Acquire/Develop changed IT service/solution component
7.5.5.4.Test IT service/solution change
7.5.5.5.Retire solutions and services
7.6.Deploy information technology solutions
7.6.1.Develop the IT deployment strategy
7.6.1.1.Establish IT services and solutions change policies
7.6.1.2.Define deployment process, procedures, and tools standards
7.6.1.3.Select deployment methodologies and tools
7.6.2.Plan and implement changes
7.6.2.1.Plan change deployment
7.6.2.2.Communicate changes to stakeholders
7.6.2.3.Administer change schedule
7.6.2.4.Train impacted users
7.6.2.5.Distribute and install change
7.6.2.6.Verify change
7.6.3.Plan and manage releases
7.6.3.1.Understand and coordinate release design and acceptance
7.6.3.2.Plan release rollout
7.6.3.3.Distribute and install release
7.6.3.4.Verify release
7.7.Deliver and support information technology services
7.7.1.Develop IT services and solution delivery strategy
7.7.1.1.Establish sourcing strategy for IT delivery
7.7.1.2.Define delivery processes, procedures, and tools standards
7.7.1.3.Select delivery methodologies and tools
7.7.2.Develop IT support strategy
7.7.2.1.Establish sourcing strategy for IT support
7.7.2.2.Define IT support services
7.7.3.Manage IT infrastructure resources
7.7.3.1.Manage IT inventory and assets
7.7.3.2.Manage IT resource capacity
7.7.4.Manage IT infrastructure operations
7.7.4.1.Deliver IT services and solutions
7.7.4.2.Perform IT operations support services
7.7.5.Support IT services and solutions
7.7.5.1.Manage availability
7.7.5.2.Manage facilities
7.7.5.3.Manage backup/recovery
7.7.5.4.Manage performance and capacity
7.7.5.5.Manage incidents
7.7.5.6.Manage problems
7.7.5.7.Manage inquiries
8.Manage Financial Resources
8.1.Perform planning and management accounting
8.1.1.Perform planning/budgeting/forecasting
8.1.1.1.Develop and maintain budget policies and procedures
8.1.1.2.Prepare periodic budgets and plans
8.1.1.3.Prepare periodic financial forecasts
8.1.2.Perform cost accounting and control
8.1.2.1.Perform inventory accounting
8.1.2.2.Perform cost of sales analysis
8.1.2.3.Perform product costing
8.1.2.4.Perform variance analysis
8.1.2.5.Report on profitability
8.1.3.Perform cost management
8.1.3.1.Determine key cost drivers
8.1.3.2.Measure cost drivers
8.1.3.3.Determine critical activities
8.1.3.4.Manage asset resource deployment and utilization
8.1.4.Evaluate and manage financial performance
8.1.4.1.Assess customer and product profitability
8.1.4.2.Evaluate new products
8.1.4.3.Perform life cycle costing
8.1.4.4.Optimize customer and product mix
8.1.4.5.Track performance of new-customer and product strategies
8.1.4.6.Prepare activity-based performance measures
8.1.4.7.Manage continuous cost improvement
8.2.Perform revenue accounting
8.2.1.Process customer credit
8.2.1.1.Establish credit policies
8.2.1.2.Analyze/Approve new account applications
8.2.1.3.Review existing accounts
8.2.1.4.Produce credit/collection reports
8.2.1.5.Reinstate or suspend accounts based on credit policies
8.2.2.Invoice customer
8.2.2.1.Maintain customer/product master files
8.2.2.2.Generate customer billing data
8.2.2.3.Transmit billing data to customers
8.2.2.4.Post receivable entries
8.2.2.5.Resolve customer billing inquiries
8.2.3.Process accounts receivable (AR)
8.2.3.1.Establish AR policies
8.2.3.2.Receive/Deposit customer payments
8.2.3.3.Apply cash remittances
8.2.3.4.Prepare AR reports
8.2.3.5.Post AR activity to the general ledger
8.2.4.Manage and process collections
8.2.4.1.Establish policies for delinquent accounts
8.2.4.2.Analyze delinquent account balances
8.2.4.3.Correspond/Negotiate with delinquent accounts
8.2.4.4.Discuss account resolution with internal parties
8.2.4.5.Process adjustments/write off balances
8.2.5.Manage and process adjustments/deductions
8.2.5.1.Establish policies/procedures for adjustments
8.2.5.2.Analyze adjustments
8.2.5.3.Correspond/Negotiate with customer
8.2.5.4.Discuss resolution with internal parties
8.2.5.5.Prepare chargeback invoices
8.2.5.6.Process related entries
8.2.6.Manage and Process Risk Adjustments
8.2.6.1.Collect data related to Medicare and exchange business
8.2.6.2.Coordinate experience analysis with medical management
8.2.6.3.Validate clinical codes and documentation
8.2.6.4.Update risk scores assumed in pricing
8.2.6.5.Report updated information to CMS
8.2.6.6.Estimate risk-score related adjustments
8.2.6.7.Coordinate with finance about payable/receivable
8.2.6.8.Record and report CMS true-up
8.3.Perform general accounting and reporting
8.3.1.Manage policies and procedures
8.3.1.1.Negotiate service-level agreements
8.3.1.2.Establish accounting policies
8.3.1.3.Set and enforce approval limits
8.3.1.4.Establish common financial systems
8.3.2.Perform general accounting
8.3.2.1.Maintain chart of accounts
8.3.2.2.Process journal entries
8.3.2.3.Process allocations
8.3.2.4.Process period end adjustments (e.g., accruals and currency conversions)
8.3.2.5.Post and reconcile intercompany transactions
8.3.2.6.Reconcile general ledger accounts
8.3.2.7.Perform consolidations and process eliminations
8.3.2.8.Prepare trial balance
8.3.2.9.Prepare and post management adjustments
8.3.3.Perform fixed-asset accounting
8.3.3.1.Establish fixed-asset policies and procedures
8.3.3.2.Maintain fixed-asset master data files
8.3.3.3.Process and record fixed-asset additions and retires
8.3.3.4.Process and record fixed-asset adjustments, enhancements, revaluations, and transfers
8.3.3.5.Process and record fixed-asset maintenance and repair expenses
8.3.3.6.Calculate and record depreciation expense
8.3.3.7.Reconcile fixed-asset ledger
8.3.3.8.Track fixed-assets including physical inventory
8.3.3.9.Provide fixed-asset data to support tax, statutory, and regulatory reporting
8.3.4.Perform financial reporting
8.3.4.1.Prepare business unit financial statements
8.3.4.2.Prepare consolidated financial statements
8.3.4.3.Perform business unit reporting/review management reports
8.3.4.4.Perform consolidated reporting/review of cost management reports
8.3.4.5.Prepare statements for board review
8.3.4.6.Produce quarterly/annual filings and shareholder reports
8.3.4.7.Produce regulatory reports
8.4.Manage fixed-asset project accounting
8.4.1.Perform capital planning and project approval
8.4.1.1.Develop capital investment policies and procedures
8.4.1.2.Develop and approve capital expenditure plans and budgets
8.4.1.3.Review and approve capital projects and fixed-asset acquisitions
8.4.1.4.Conduct financial justification for project approval
8.4.2.Perform capital project accounting
8.4.2.1.Create project account codes
8.4.2.2.Record project-related transactions
8.4.2.3.Monitor and track capital projects and budget spending
8.4.2.4.Close/capitalize projects
8.4.2.5.Measure financial returns on completed capital projects
8.5.Process payroll
8.5.1.Report time
8.5.1.1.Establish policies and procedures
8.5.1.2.Collect and record employee time worked
8.5.1.3.Analyze and report paid and unpaid leave
8.5.1.4.Monitor regular, overtime, and other hours
8.5.1.5.Analyze and report employee utilization
8.5.2.Manage pay
8.5.2.1.Enter employee time worked into payroll system
8.5.2.2.Maintain and administer employee earnings information
8.5.2.3.Maintain and administer applicable deductions
8.5.2.4.Monitor changes in tax status of employees
8.5.2.5.Process and distribute payments
8.5.2.6.Process and distribute manual checks
8.5.2.7.Process period-end adjustments
8.5.2.8.Respond to employee payroll inquiries
8.5.3.Process payroll taxes
8.5.3.1.Calculate and pay applicable payroll taxes
8.5.3.2.Produce and distribute employee annual tax statements
8.5.3.3.File regulatory payroll tax forms
8.6.Process accounts payable and expense reimbursements
8.6.1.Process accounts payable (AP)
8.6.1.1.Verify AP pay file with purchase order vendor master file
8.6.1.2.Maintain/Manage electronic commerce
8.6.1.3.Audit invoices and key data in AP system
8.6.1.4.Approve payments
8.6.1.5.Process financial accruals and reversals
8.6.1.6.Process taxes
8.6.1.7.Research/Resolve exceptions
8.6.1.8.Process payments
8.6.1.9.Respond to AP inquiries
8.6.1.10.Retain records
8.6.1.11.Adjust accounting records
8.6.2.Process expense reimbursements
8.6.2.1.Establish and communicate expense reimbursement policies and approval limits
8.6.2.2.Capture and report relevant tax data
8.6.2.3.Approve reimbursements and advances
8.6.2.4.Process reimbursements and advances
8.6.2.5.Manage personal accounts
8.7.Perform liability and insurance reserve valuations
8.7.1.Reconcile claim cash flows
8.7.1.1.Compile check register entries
8.7.1.2.Compare check register to cash flow invoices
8.7.1.3.Reconcile differences
8.7.1.4.Process prior period membership eligibility-related adjustments
8.7.1.5.Process prior period inter-company subrogation-related adjustments
8.7.1.6.Allocate other top side adjustments
8.7.2.Apply valuation standards
8.7.2.1.Compile claim data into required format
8.7.2.2.Validate data form and content
8.7.2.3.Apply business conditions, operating environment and other assumptions
8.7.2.4.Perform calculations per actuarial and regulatory standards
8.7.2.5.Reconcile and validate results for changes in business and/or operating environment
8.7.2.6.Review results of analysis with management
8.7.2.7.Process ledger entries to line of business and legal entity
8.7.2.8.Issue actuarial opinion by qualified actuary
8.7.3.Manage reserving controls, policies and procedures
8.7.3.1.Establish scope and governance of reserve setting function
8.7.3.2.Establish and publish security and controls guidelines
8.7.3.3.Document reserve setting protocols and responsibilities
8.7.3.4.Monitor reserve setting and claim reconciliation procedures
8.7.3.5.Audit reserve setting procedures
8.7.3.6.Revise and update reserve and liability determination procedures for regulatory or controls related items
8.7.3.7.Develop and confirm internal controls
8.7.3.8.Define system security requirements and permissions
8.8.Manage treasury operations
8.8.1.Manage treasury policies and procedures
8.8.1.1.Establish scope and governance of treasury operations
8.8.1.2.Establish and publish treasury policies
8.8.1.3.Develop treasury procedures
8.8.1.4.Monitor treasury procedures
8.8.1.5.Audit treasury procedures
8.8.1.6.Revise treasury procedures
8.8.1.7.Develop and confirm internal controls for treasury
8.8.1.8.Define system security requirements
8.8.2.Manage cash
8.8.2.1.Manage and reconcile cash positions
8.8.2.2.Manage cash equivalents
8.8.2.3.Process and oversee electronic fund transfers (EFTs)
8.8.2.4.Develop cash flow forecasts
8.8.2.5.Manage cash flows
8.8.2.6.Produce cash management accounting transactions and reports
8.8.2.7.Manage and oversee banking relationships
8.8.2.8.Analyze, negotiate, resolve, and confirm bank fees
8.8.3.Manage in-house bank accounts
8.8.3.1.Manage in-house bank accounts for subsidiaries
8.8.3.2.Manage and facilitate inter-company borrowing transactions
8.8.3.3.Manage centralized outgoing payments on behalf of subsidiaries
8.8.3.4.Manage central incoming payments on behalf of subsidiaries
8.8.3.5.Manage internal payments and netting transactions
8.8.3.6.Calculate interest and fees for in-house bank accounts
8.8.3.7.Provide account statements for in-house bank accounts
8.8.4.Manage debt and investment
8.8.4.1.Manage financial intermediary relationships
8.8.4.2.Manage liquidity
8.8.4.3.Manage issuer exposure
8.8.4.4.Process and oversee debt and investment transactions
8.8.4.5.Process and oversee foreign currency transactions
8.8.4.6.Produce debt and investment accounting transaction reports
8.8.4.7.Process and oversee interest rate transactions
8.8.4.8.Manage reserves compliance
8.8.5.Monitor and execute risk and hedging transactions
8.8.5.1.Manage interest-rate risk
8.8.5.2.Manage foreign-exchange risk
8.8.5.3.Manage exposure risk
8.8.5.4.Develop and execute hedging transactions
8.8.5.5.Evaluate and refine hedging positions
8.8.5.6.Produce hedge accounting transactions and reports
8.8.5.7.Monitor credit
8.9.Perform risk based capital and other solvency based reporting
8.9.1.Collect required documentation and national association insurance commissioners guidelines
8.9.1.1.Procure update national association insurance commissioners guidelines
8.9.1.2.Update procedures manual and tools
8.9.1.3.Manage data collection
8.9.2.Compile documentation associated with each risk based capital component
8.9.2.1.Validate associated reported amounts within each risk based capital risk categories
8.9.2.2.Manage collection of documentation supporting each entry
8.9.2.3.Update reported amounts and documentation
8.9.3.Quantify risks in risk based capital formula and worksheets
8.9.3.1.Manage application of risk factors
8.9.3.2.Validate risk exposures against enterprise risk management risk appetites
8.9.3.3.Record quantified risk amounts in models
8.9.4.Validate calculations against regulatory updates
8.9.4.1.Manage collection of calculated amounts
8.9.4.2.Validate regulatory guidance and policies
8.9.5.Perform sensitivity testing
8.9.5.1.Design sensitivity tests and scenarios
8.9.5.2.Review testing parameters with business owners
8.9.5.3.Perform sensitivity tests
8.9.5.4.Discuss risk and sensitivity results
8.9.5.5.Escalate risk awareness against strategies and market objectives
8.9.6.Update analysis for changes in treasury management, business operations
8.9.7.Finalize and file risk based capital report
8.9.8.Coordinate required amounts with treasury (cash) management
8.10.Manage internal controls
8.10.1.Establish internal controls, policies, and procedures
8.10.1.1.Establish board of directors and audit committee
8.10.1.2.Define and communicate code of ethics
8.10.1.3.Assign roles and responsibility for internal controls
8.10.1.4.Define business process objectives and risks
8.10.1.5.Define entity/unit risk tolerances
8.10.2.Operate controls and monitor compliance with internal controls policies and procedures
8.10.2.1.Design and implement control activities
8.10.2.2.Monitor control effectiveness
8.10.2.3.Remediate control deficiencies
8.10.2.4.Create compliance function
8.10.2.5.Operate compliance function
8.10.2.6.Implement and maintain controls-related enabling technologies and tools
8.10.3.Report on internal controls compliance
8.10.3.1.Report to external auditors
8.10.3.2.Report to regulators, share-/debt-holders, securities exchanges, etc.
8.10.3.3.Report to third parties (e.g., business partners)
8.10.3.4.Report to internal management
8.11.Manage taxes
8.11.1.Develop tax strategy and plan
8.11.1.1.Develop foreign, national, state, and local tax strategy
8.11.1.2.Consolidate and optimize total tax plan
8.11.1.3.Maintain tax master data
8.11.2.Process taxes
8.11.2.1.Perform tax planning/strategy
8.11.2.2.Prepare returns
8.11.2.3.Prepare foreign taxes
8.11.2.4.Calculate deferred taxes
8.11.2.5.Account for taxes
8.11.2.6.Monitor tax compliance
8.11.2.7.Address tax inquiries
8.12.Manage international funds/consolidation
8.12.1.Monitor international rates
8.12.2.Manage transactions
8.12.3.Monitor currency exposure/hedge currency
8.12.4.Report results
8.13.Conduct actuarial services
8.13.1.Develop trends analysis
8.13.1.1.Develop cost trend projects
8.13.2.Conduct actuarial informatics/reporting
8.13.3.Manage experience rating
8.13.3.1.Perform pre-sale underwriting review
8.13.3.2.Review claim experience
8.13.3.3.Determine premium
8.13.4.Perform pool/block rating management
8.13.4.1.File with department of insurance
8.13.4.2.Develop rating methodology
8.13.4.3.Publish pool/block rates
8.13.4.4.Manage rating tools
8.13.5.Conduct pool/block underwriting
8.13.5.1.Review experience and history
8.13.5.2.Determine pool/block premium
8.13.6.Provide underwriting support
8.13.7.Manage regulatory requirements and compliance
8.13.7.1.Compile rate filing documentation
8.13.7.2.Upload information into state rating system(s)
8.13.7.3.Perform quality control testing on load
8.13.7.4.Validate rate load and internal system consistency
8.13.7.5.Compile rate assumptions and documentation
8.13.7.6.Issue actuarial memorandum by qualified actuary
8.14.Perform global trade services
8.14.1.Screen sanctioned party list
8.14.2.Control exports and imports
8.14.3.Classify products
8.14.4.Calculate duty
8.14.5.Communicate with customs
8.14.6.Document trade
8.14.7.Process trade preferences
8.14.8.Handle restitution
8.14.9.Prepare letter of credit
9.Acquire, Construct and Manage Assets
9.1.Design and construct/acquire nonproductive assets
9.1.1.Develop property strategy and long-term vision
9.1.1.1.Confirm alignment of property requirements with business strategy
9.1.1.2.Assess the external environment
9.1.1.3.Make build-or-buy decision
9.1.2.Develop, construct, and modify sites
9.1.3.Plan facility
9.1.3.1.Design facility
9.1.3.2.Analyze budget
9.1.3.3.Select property
9.1.3.4.Negotiate terms for facility
9.1.3.5.Manage construction or modification to building
9.1.4.Provide workspace and assets
9.1.4.1.Acquire workspace and assets
9.1.4.2.Change fit/form/function of workspace and assets
9.2.Plan maintenance work
9.2.1.Perform routine maintenance
9.2.2.Perform corrective maintenance
9.2.3.Overhaul equipment
9.2.4.Manage facilities operations
9.2.4.1.Relocate people
9.2.4.2.Relocate material and tools
9.3.Obtain and install assets, equipment, and tools
9.3.1.Develop ongoing maintenance policies for productive assets
9.3.1.1.Analyze assets, and predict maintenance requirements
9.3.1.2.Develop approach to integrate preventive maintenance into production schedule
9.3.2.Obtain and install equipment
9.3.2.1.Design engineering solution for the manufacturing process
9.3.2.2.Install and commission equipment
9.4.Dispose of productive and nonproductive assets
9.4.1.Develop exit strategy
9.4.2.Perform sale or trade
9.4.3.Perform abandonment
10.Manage Enterprise Risk, Compliance, Remediation and Resiliency
10.1.Manage enterprise risk
10.1.1.Establish the enterprise risk framework and policies
10.1.1.1.Determine risk tolerance for organization
10.1.1.2.Develop and maintain enterprise risk policies and procedures
10.1.1.3.Identify and implement enterprise risk management tools
10.1.1.4.Coordinate the sharing of risk knowledge across the organization
10.1.1.5.Prepare and report enterprise risk to executive management and board
10.1.2.Oversee and coordinate enterprise risk management activities
10.1.2.1.Identify enterprise level risks
10.1.2.2.Assess risks to determine which to mitigate
10.1.2.3.Develop risk mitigation and management strategy, and integrate with existing performance management processes
10.1.2.4.Verify business unit and functional risk mitigation plans are implemented
10.1.2.5.Ensure risks and risk mitigation actions are monitored
10.1.2.6.Report on risk activities
10.1.3.Coordinate business unit and functional risk management activities
10.1.3.1.Ensure that each business unit / function follows the enterprise risk management process
10.1.3.2.Ensure that each business unit/function follows the enterprise risk reporting process
10.1.4.Manage business unit and function risk
10.1.4.1.Identify risks
10.1.4.2.Assess risks using enterprise risk framework policies and procedures
10.1.4.3.Develop mitigation plans for risks
10.1.4.4.Implement mitigation plans for risks
10.1.4.5.Monitor risks
10.1.4.6.Analyze risk activities and update plans
10.1.4.7.Report on risk activities
10.1.4.8.Manage ORSA regulatory compliance process
10.2.Manage compliance
10.2.1.Establish compliance framework and policies
10.2.1.1.Develop enterprise compliance policies and procedures
10.2.1.2.Implement enterprise compliance activities
10.2.1.3.Manage internal audits
10.2.1.4.Maintain controls-related technologies and tools
10.2.2.Manage regulatory compliance
10.2.2.1.Develop regulatory compliance procedures
10.2.2.2.Identify applicable regulatory requirements
10.2.2.3.Monitor the regulatory environment for changing or emerging regulations
10.2.2.4.Assess current compliance position, and identify weaknesses or shortfalls therein
10.2.2.5.Implement missing or stronger regulatory compliance controls and policies
10.2.2.6.Monitor and test, on an ongoing and scheduled basis, regulatory compliance position and existing controls, defining controls that should be added, removed, or modified as required
10.2.2.7.Maintain relationships with regulators as appropriate
10.3.Manage remediation efforts
10.3.1.Create remediation plans
10.3.2.Contact and confer with experts
10.3.3.Identify/dedicate resources
10.3.4.Investigate legal aspects
10.3.5.Investigate damage cause
10.3.6.Amend or create policy
10.4.Manage business resiliency
10.4.1.Develop the business resilience strategy
10.4.2.Perform continuous business operations planning
10.4.3.Test continuous business operations
10.4.4.Maintain continuous business operations
10.4.5.Share knowledge of specific risks across other parts of the organization
10.5.Manage fraud, abuse and payment integrity
10.5.1.Develop strategy and monitoring program
10.5.1.1.Determine capacity and size of investigation unit
10.5.1.2.Agree on pre-adjudication approach and technology
10.5.1.3.Agree on post-adjudication approach and technology
10.5.1.4.Agree on retrospective/post payment approach and recovery
10.5.1.5.Conduct a vendor selection process
10.5.1.6.Implement anti-fraud and abuse solution
10.5.2.Manage investigation unit and anti fraud and abuse operations
10.5.2.1.Set program thresholds to match investigation unit capacity
10.5.2.2.Scan incoming claims to detect anomalies and suspicious patterns
10.5.2.3.Score and prioritize transactions according to risk level
10.5.2.4.Flag and hold suspicious transactions for further investigation
10.5.2.5.Manage investigation case and bring to conclusion
11.Manage External Relationships
11.1.Build investor relationships
11.1.1.Plan, build, and manage lender relations
11.1.2.Plan, build, and manage analyst relations
11.1.3.Communicate with shareholders
11.2.Manage government and industry relationships
11.2.1.Manage government relations
11.2.2.Manage relations with quasi-government bodies
11.2.3.Manage relations with trade or industry groups
11.2.4.Manage lobby activities
11.2.5.Manage government review
11.3.Manage relations with board of directors
11.3.1.Report results
11.3.2.Report audit findings
11.4.Manage legal and ethical issues
11.4.1.Create ethics policies
11.4.2.Manage corporate governance policies
11.4.3.Develop and perform preventive law programs
11.4.4.Ensure compliance
11.4.4.1.Plan and initiate compliance program
11.4.4.2.Execute compliance program
11.4.5.Manage outside counsel
11.4.5.1.Assess problem and determine work requirements
11.4.5.2.Engage/Retain outside counsel if necessary
11.4.5.3.Receive strategy/budget
11.4.5.4.Receive work product and manage/monitor case and work performed
11.4.5.5.Process payment for legal services
11.4.5.6.Track legal activity/performance
11.4.6.Protect intellectual property
11.4.6.1.Manage copyrights and patents
11.4.6.2.Maintain intellectual property rights and restrictions
11.4.6.3.Administer licensing terms
11.4.6.4.Administer options
11.4.7.Resolve disputes and litigations
11.4.8.Provide legal advice/counseling
11.4.9.Negotiate and document agreements/contracts
11.5.Manage public relations program
11.5.1.Manage community relations
11.5.2.Manage media relations
11.5.3.Promote political stability
11.5.4.Create press releases
11.5.5.Issue press releases
12.Develop and Manage Business Capabilities
12.1.Manage business processes
12.1.1.Establish and maintain process management governance
12.1.1.1.Define and manage governance approach
12.1.1.2.Establish and maintain process tools and templates
12.1.1.3.Assign and support process ownership
12.1.1.4.Perform process governance activities
12.1.2.Define and manage process frameworks
12.1.2.1.Establish and maintain process framework
12.1.2.2.Identify cross-functional processes
12.1.3.Define processes
12.1.3.1.Scope processes
12.1.3.2.Analyze processes
12.1.3.3.Map processes
12.1.3.4.Publish processes
12.1.4.Manage process performance
12.1.4.1.Provide process training
12.1.4.2.Support process execution
12.1.4.3.Measure and report process performance
12.1.5.Improve processes
12.1.5.1.Identify and select improvement opportunities
12.1.5.2.Manage improvement projects
12.1.5.3.Perform continuous improvement activities
12.2.Manage portfolio, program, and project
12.2.1.Manage portfolio
12.2.1.1.Establish portfolio strategy
12.2.1.2.Define portfolio governance
12.2.1.3.Monitor and control portfolio
12.2.2.Manage programs
12.2.2.1.Establish program structure and approach
12.2.2.2.Manage program stakeholders and partners
12.2.2.3.Manage program execution
12.2.2.4.Review and report program performance
12.2.3.Manage projects
12.2.3.1.Establish project scope
12.2.3.1.1.Identify project requirements and objectives
12.2.3.1.2.Identify project resource requirements
12.2.3.1.3.Assess culture and readiness for project management approach
12.2.3.1.4.Identify appropriate project management methodologies
12.2.3.1.5.Create business case and obtain funding
12.2.3.1.6.Develop project measures and indicators
12.2.3.2.Develop project plans
12.2.3.2.1.Define roles and resources
12.2.3.2.2.Identify specific IT requirements
12.2.3.2.3.Create training and communication plans
12.2.3.2.4.Design recognition and reward approaches
12.2.3.2.5.Design and plan launch of project
12.2.3.2.6.Deploy the project
12.2.3.3.Execute projects
12.2.3.3.1.Evaluate impact of project management (strategy and projects) on measures and outcomes
12.2.3.3.2.Report the status of project
12.2.3.3.3.Manage project scope
12.2.3.3.4.Promote and sustain activity and involvement
12.2.3.3.5.Realign and refresh project management strategy and approaches
12.2.3.4.Review and report project performance
12.2.3.5.Close projects
12.3.Manage enterprise quality
12.3.1.Establish quality requirements
12.3.1.1.Define critical-to-quality characteristics
12.3.1.2.Define preventive quality activities
12.3.1.3.Develop quality controls
12.3.1.3.1.Define process steps for controls (or integration points)
12.3.1.3.2.Define sampling plan
12.3.1.3.3.Identify measurement methods
12.3.1.3.4.Define required competencies
12.3.1.4.Prove capability to assess compliance with requirements
12.3.1.5.Finalize quality plan
12.3.2.Evaluate performance to requirements
12.3.2.1.Test against quality plan
12.3.2.1.1.Conduct test and collect data
12.3.2.1.2.Record result(s)
12.3.2.1.3.Determine disposition of result(s)
12.3.2.2.Assess results of tests
12.3.2.2.1.Assess sample significance
12.3.2.2.2.Summarize result(s)
12.3.2.2.3.Recommend actions
12.3.2.2.4.Decide next steps
12.3.3.Manage non-conformance
12.3.3.1.Assess potential impact
12.3.3.2.Determine immediate action(s)
12.3.3.3.Identify root cause(s)
12.3.3.4.Take corrective or preventative action
12.3.3.5.Close non-conformance
12.3.4.Implement and maintain the enterprise quality management system (EQMS)
12.3.4.1.Define the quality strategy
12.3.4.2.Plan and deploy the EQMS scope, targets, and goals
12.3.4.3.Identify core EQMS processes, controls, and metrics
12.3.4.4.Develop and document EQMS policies, procedures, standards, and measures
12.3.4.5.Assess the EQMS performance
12.3.4.6.Create environment and capability for EQMS improvement(s)
12.3.4.6.1.Reward quality excellence
12.3.4.6.2.Create and maintain quality partnerships
12.3.4.6.3.Maintain talent capabilities and competencies
12.3.4.6.4.Incorporate EQMS messaging into communication channels
12.3.4.6.5.Assure independent EQMS management access to appropriate authority in the organization
12.3.4.6.6.Transfer proven EQMS methods
12.4.Manage change
12.4.1.Plan for change
12.4.1.1.Select process improvement methodology
12.4.1.2.Assess readiness for change
12.4.1.3.Determine stakeholders
12.4.1.4.Engage/Identify champion
12.4.1.5.Form design team
12.4.1.6.Define scope
12.4.1.7.Understand current state
12.4.1.8.Define future state
12.4.1.9.Conduct organizational risk analysis
12.4.1.9.1.Assess cultural issues
12.4.1.9.2.Establish accountability for change management
12.4.1.9.3.Identify barriers to change
12.4.1.9.4.Determine change enablers
12.4.1.9.5.Identify resources and develop measures
12.4.2.Design the change
12.4.2.1.Assess connection to other initiatives
12.4.2.2.Develop change management plans
12.4.2.3.Develop training plan
12.4.2.4.Develop communication plan
12.4.2.5.Develop rewards/incentives plan
12.4.2.6.Establish change adoption metrics
12.4.2.7.Establish/Clarify new roles
12.4.2.8.Identify budget/roles
12.4.3.Implement change
12.4.3.1.Create commitment for improvement/change
12.4.3.2.Re-engineer business processes and systems
12.4.3.3.Support transition to new roles or exit strategies for incumbents
12.4.3.4.Monitor change
12.4.4.Sustain improvement
12.4.4.1.Monitor improved process performance
12.4.4.2.Capture and reuse lessons learned from change process
12.4.4.3.Take corrective action as necessary
12.5.Develop and manage enterprise-wide knowledge management (KM) capability
12.5.1.Develop KM strategy
12.5.1.1.Develop governance model
12.5.1.2.Establish central KM core group
12.5.1.3.Define roles and accountability of core group versus operating units
12.5.1.4.Develop funding models
12.5.1.5.Identify links to key initiatives
12.5.1.6.Develop core KM methodologies
12.5.1.7.Assess IT needs and engage IT function
12.5.1.8.Develop training and communication plans
12.5.1.9.Develop change management approaches
12.5.1.9.1.Develop strategic measures and indicators
12.5.2.Assess KM capabilities
12.5.2.1.Assess maturity of existing KM initiatives
12.5.2.2.Evaluate existing KM approaches
12.5.2.3.Identify gaps and needs
12.5.2.4.Enhance/Modify existing KM approaches
12.5.2.5.Develop new KM approaches
12.5.2.6.Implement new KM approaches
12.5.3.Identify and plan projects
12.5.3.1.Identify strategic opportunities to apply project management approach(es)
12.5.3.2.Design process for knowledge sharing, capture, and use
12.5.3.3.Assess alignment with business goals
12.6.Measure and benchmark
12.6.1.Create and manage organizational performance strategy
12.6.1.1.Create enterprise measurement systems model
12.6.1.2.Measure process productivity
12.6.1.3.Measure cost effectiveness
12.6.1.4.Measure staff efficiency
12.6.1.5.Measure cycle time
12.6.2.Benchmark performance
12.6.2.1.Conduct performance assessments
12.6.2.2.Develop benchmarking capabilities
12.6.2.3.Conduct internal process and external competitive benchmarking
12.6.2.4.Conduct gap analysis to understand need for change and degree needed
12.6.2.5.Establish need for change
12.7.Manage environmental health and safety (EHS)
12.7.1.Determine environmental health and safety impacts
12.7.1.1.Evaluate environmental impact of products, services, and operations
12.7.1.2.Conduct health and safety and environmental audits
12.7.2.Develop and execute functional EHS program
12.7.2.1.Identify regulatory and stakeholder requirements
12.7.2.2.Assess future risks and opportunities
12.7.2.3.Create EHS policy
12.7.2.4.Record and manage EHS events
12.7.3.Train and educate functional employees
12.7.3.1.Communicate EHS issues to stakeholders and provide support
12.7.4.Monitor and manage functional EHS management program
12.7.4.1.Manage EHS costs and benefits
12.7.4.2.Measure and report EHS performance
12.7.4.3.Implement emergency response program
12.7.4.4.Implement pollution prevention program
12.7.4.5.Provide employees with EHS support
« Назад ||
