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Процессная модель APQC Healthcare Insurance (Медицинское страхование)

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Процессная модель APQC Healthcare Insurance

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 and evaluate competition economic trends political and regulatory issues new technology innovations demographics social and cultural changes ecological concerns health care insurance exchange level of participation and timing

      1.1.2.Survey market and determine customer needs and wants qualitative/quantitative assessments and assess customer needs

      1.1.3.Perform internal analysis organizational characteristics baselines for current processes systems and technology financial positions enterprise core competencies

      1.1.4.Establish strategic vision stakeholders around strategic vision strategic vision to stakeholders

    1.2.Develop business strategy

      1.2.1.Develop overall mission statement current business mission mission

      1.2.2.Evaluate strategic options to achieve the objectives strategic options and analyze impact of each option sustainability strategy global support and shared services strategy lean/continuous improvement strategy

      1.2.3.Conduct organization restructuring opportunities restructuring opportunities due-diligence deal options

 acquisition options

 merger options

 de-merger options

 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.) breadth and depth of organizational structure job-specific roles mapping and value-added analyses role activity diagrams to assess hand-off activity organization redesign workshops the relationships between organizational units role analysis and activity diagrams for key processes organizational implication of feasible alternatives 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 potential improvements to existing products and services potential new products and services

      2.1.3.Perform discovery research new technologies new technologies feasibility of integrating new leading technologies into product/service concepts

      2.1.4.Confirm alignment of product/service concepts with business strategy and develop cost and quality targets and select new product/service concepts development timing targets for product/service offering modifications

      2.1.5.Manage product and service life cycle new products/services outdated products/services 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 resources to product/service project high-level business case and technical assessment product/service design specifications design specifications mandatory and elective external reviews (legal, regulatory, standards, internal) prototypes quality and reliability problems in-house product/service testing and evaluate feasibility design/development performance indicators on design with suppliers and contract manufacturers

      2.2.2.Test market for new or revised products and services detailed market study customer tests and interviews product/service characteristics and business cases technical requirements requirements for changes to manufacturing/delivery processes

      2.2.3.Prepare for production and test prototype production and/or service delivery process and obtain necessary materials and equipment and validate production process or methodology production runs engineering change 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 customer and market research market segments market and industry trends competing organizations, competitive/substitute products existing products/brands internal and external business environment

      3.1.2.Evaluate and prioritize market opportunities market opportunities target segments opportunities consistent with capabilities and overall business strategy opportunities

    3.2.Develop marketing strategy

      3.2.1.Define offering and customer value proposition offering and positioning value proposition including brand positioning for target segments value proposition with target segments new branding

      3.2.2.Define pricing strategy to align to value proposition guidelines for applying pricing of products/services pricing strategies/policies

      3.2.3.Define and manage channel strategy channel attributes and partners channel fit with target segments channels for target segments

      3.2.4.Design brochures/collateral

    3.3.Develop sales strategy

      3.3.1.Develop sales forecast current and historic order information sales trends and patterns sales forecast historical and planned promotions and events

      3.3.2.Develop sales partner/alliance relationships alliance opportunities alliance programs and methods for selecting and managing relationships alliances partner and alliance management strategies partner and alliance management goals

      3.3.3.Perform broker channel management brokers and agents with brokers and agents

      3.3.4.Establish overall sales budgets product revenue variable costs overhead and fixed costs net profit 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 marketing alignment to business strategy costs of marketing marketing budget

      3.4.3.Develop and manage media media objectives marketing messages target audience media provider and execute advertising and execute other marketing campaigns/programs brand/product marketing plan performance

      3.4.4.Develop and manage pricing pricing based on volume/unit forecast pricing plan pricing performance pricing as needed

    3.5.Develop and manage sales plans

      3.5.1.Manage sales collateral proposal templates and manage promotional activities

 promotional concepts

 and test promotional activities

 promotional activities

 promotional performance metrics

 promotional performance metrics

 learning into future/planned consumer promotions customer management measures

 customer loyalty/lifetime value

 customer revenue trend

 customer attrition and retention rates

 customer metrics

 customer strategies, objectives, and plans based on metrics

 purchasing behavior

 customer campaigns

 customer market research Campaigns

      3.5.2.Develop and manage packaging strategy packaging strategy packaging options packaging strategy packaging

    3.6.Develop and manage sales plans

      3.6.1.Generate leads potential customers leads

      3.6.2.Manage customers and accounts sales/key account plan customer relationships customer master data payment profile administration

 payment allocation

 responsible party

 billing attributes

 billing preferences

      3.6.3.Manage customer sales direct sales to groups sales calls pre-sales activities



 contracts the sale outcome of sales process

      3.6.4.Manage sales orders and validate sales orders and maintain customer account information availability fulfillment process orders into system and identify/perform cross-sell/up-sell activity back orders and updates order inquiries including post-order fulfillment transactions

      3.6.5.Manage sales force sales resource allocation sales force incentive plan

      3.6.6.Manage sales partners and alliances sales and product training to sales partners/alliances sales forecast by partner/alliance on partner and alliance commissions partner/alliance results channel partner master data distribution channels

    3.7.Enroll and onboard membership

      3.7.1.Validate members CMS authorization member information enrollment eligibility

      3.7.2.Profile members and/or modify manage member identifier number or update member demographics or update confidential communication profile or update ember provider panel/PCP coverage enrollments associate member healthcare information benefits

      3.7.3.Conduct fulfillment administration appropriate member welcome Letters ID Card Template Benefit Booklet

      3.7.4.Install and maintain account/case up account structure and maintenance group demographics group contacts group information group participation requirements 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 manufacturing goals labor and materials policies outsourcing policies manufacturing capital expense policies capacities production network and supply constraints production process production workplace layout and infrastructure

      4.1.2.Manage demand for products and services baseline forecasts with customers consensus forecast available to promise activity against forecast and revise forecast and revise forecasting approach forecast accuracy

      4.1.3.Create materials plan unconstrained plan with supplier and contract manufacturers critical materials and supplier capacity material specifications constrained plan production balance and control

      4.1.4.Create and manage master production schedule site-level production plan and schedule work-in-progress inventory with suppliers site-level production plan and schedule master production schedule and plan

      4.1.5.Plan distribution requirements master data finished goods inventory requirements at destination requirements at destination consolidation at source collaborative replenishment planning requirements for partners destination dispatch plan dispatch plan attainment destination load plans partner load plan cost of supply capacity utilization

      4.1.6.Establish distribution planning constraints distribution center layout constraints inventory management constraints transportation management constraints

      4.1.7.Review distribution planning policies distribution network sourcing relationships dynamic deployment policies

      4.1.8.Assess distribution planning performance appropriate performance indicators (metrics) monitoring frequency performance measures performance trends performance benchmark gaps appropriate reports performance improvement plan

      4.1.9.Develop quality standards and procedures quality targets standard testing procedures quality specifications

    4.2.Manage health care delivery

      4.2.1.Generate medical informatics existing network analysis gap in care analysis service and procedure analysis

      4.2.2.Perform health program management health programs health management programs health program enrollment health program analytics health programs

      4.2.3.Perform medical policy management medical policy rules medical policy medical policy appeal

      4.2.4.Perform utilization management prior-authorizations/pre-certify provider referral medical policy

    4.3.Support healthcare management

      4.3.1.Develop healthcare management policy, planning, and strategy and maintain contracting and reimbursement policies and maintain medical policies and maintain network strategy and plan contracting standards contract templates and maintain standard fee schedules provider rate sheets

      4.3.2.Develop and manage the network and recruit providers and re-credential providers and contract with providers providers provider practice/group arrangements provider market intelligence provider performance indicators and monitor providers revenue cycle provider communications and train providers provider data and directories quality and performance of the network management process ancillary services lab services other ancillary services

      4.3.3.Perform pre-pay provider reimbursement encounter information capitation reimbursement and reconcile specialized reimbursements

      4.3.4.Perform medical management utilization management case management and disease management with members referral management for members wellness and patient education

      4.3.5.Manage service provider relationships provider relationships and loyalty provider inquiry intake research and resolve inquiries orientation, education, and feedback to providers

      4.3.6.Conduct provider performance management and train providers Provider contracts Provider service quality

      4.3.7.Communicate with providers provider communication campaigns provider requests

      4.3.8.Conduct pharmacy benefit management member drug utilization drug Formulary formulary rebate Mail order pharmacy with members

    4.4.Adjudicate claims and process reimbursement

      4.4.1.Develop claim/encounter informatics and report on claim processing activity quality assurance and auditing procedures critical inquiry process and appeals

      4.4.2.Adjudicate claims coverage/benefits clinical editing covered service eligibility

      4.4.3.Process intake of claims paper claims into claims system OCR claims into claims system electronic claims into claims system interactive claims into claims system claims imaging and record within claims system claim control ID claims for processing pre-edit claims examination claims

      4.4.4.Perform claim policy management claim policy rules claim policy claim policy appeal

      4.4.5.Communicate claim outcomes remittance advise explanation of benefits

      4.4.6.Perform benefits management benefits support 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 procurement plan purchasing requirements inventory strategy needs to supply capabilities organization’s spend profile opportunities to improve efficiency and value with suppliers to identify sourcing opportunities

      4.7.2.Select suppliers and develop/maintain contracts suppliers and validate suppliers and establish contracts contracts

      4.7.3.Order materials and services requisitions requisitions vendor quotes purchase orders orders and satisfy inquiries receipt of goods exceptions

      4.7.4.Manage suppliers supplier information procurement and vendor performance inventory and production processes quality of product delivered

    4.8.Produce/Manufacture/Deliver product

      4.8.1.Schedule production line level plan detailed schedule production orders and create lots preventive (planned) maintenance (preventive maintenance orders) requested (unplanned) maintenance (work order cycle) production orders and create lots

      4.8.2.Produce product raw material inventory detailed line schedule maintenance issues defective items production performance

      4.8.3.Perform quality testing test equipment testing using the standard testing procedure test results

      4.8.4.Maintain production records and manage lot traceability lot numbering system lot use

    4.9.Deliver service to customer

      4.9.1.Confirm specific service requirements for individual customer customer request customer profile service order

      4.9.2.Identify and schedule resources to meet service requirements resourcing plan and schedule service order fulfillment schedule service order

      4.9.3.Provide service to specific customers daily service order fulfillment schedule resources order fulfillment progress order fulfillment block completion

      4.9.4.Ensure quality of service completed orders for feedback incomplete orders and service failures customer feedback on services delivered customer feedback on services delivered

    4.10.Manage logistics and warehousing

      4.10.1.Define logistics strategy customer service requirements into logistics requirements logistics network outsourcing needs and maintain delivery service policy transportation schedules and costs key performance measures

      4.10.2.Plan and manage inbound material flow inbound material receipts inbound material flow inbound delivery performance flow of returned products

      4.10.3.Operate warehousing inventory deployment, inspect, and store inbound deliveries product availability, pack, and ship product for delivery inventory accuracy third-party logistics storage and shipping performance physical finished goods inventory

      4.10.4.Operate outbound transportation, transport, and deliver outbound product carrier delivery performance transportation fleet and audit carrier invoices and documents

      4.10.5.Manage returns; manage reverse logistics and process returns reverse logistics salvage activities and process warranty claims 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) existing customers 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 service policies and procedures service routing and workflow documented service level agreements

    5.2.Plan and manage customer service operations

      5.2.1.Plan and manage customer service work force volume of customer service contacts customer service work force work force utilization and evaluate quality of customer interactions with customer service representatives

      5.2.2.Manage customer service requests/inquiries customer requests/inquiries customer requests/inquiries to customer requests/inquiries

      5.2.3.Manage customer complaints customer complaints customer complaints customer complaints to customer complaints

      5.2.4.Conduct correspondence management correspondence to case correspondence image upon request

      5.2.5.Perform member outreach product information wellness information to members

      5.2.6.Manage appeals and grievances provider claims grievances provider claims appeals process member service grievances customer service grievances process

      5.2.7.Perform membership inquiry/eligibility and coverage procedures

      5.2.8.Perform billing and payment support processes invoice by member billing and payment profile payment status by member payment reminder to member

      5.2.9.Maintain nurse line help desk wellness support to members 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 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 and solicit post-sale customer feedback on products and services post-sale customer feedback on ad effectiveness product and service satisfaction data and identify improvement opportunities customer feedback to product management on products and services

      5.5.2.Measure customer satisfaction with customer-complaint handling and resolution customer feedback on complaint handling and resolution customer complaint data and identify improvement opportunities

      5.5.3.Measure customer satisfaction with products and services and solicit post-sale customer feedback on products and services post-sale customer feedback on ad effectiveness product and service satisfaction data and identify improvement opportunities 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 strategic HR needs HR and business function roles and accountability HR costs HR measures HR strategies strategy for HR systems/technologies/tools

      6.1.2.Develop and implement workforce strategy and policies skill requirements according to corporate strategy and market environment employee resourcing requirements per unit/organization compensation plan succession plan employee diversity plan other HR programs HR policies HR policies employee benefits work force strategy models

      6.1.3.Monitor and update strategy, plans, and policies realization of objectives contribution to business strategy plans and provide updates to stakeholders value added from HR function and revise HR plans

      6.1.4.Develop competency management models

    6.2.Recruit, source, and select employees

      6.2.1.Manage employee requisitions staffing plan to work force plan and business unit strategies/resource needs and open job requisitions job descriptions requisitions internal/external job posting Web sites requisitions hiring manager requisition dates

      6.2.2.Recruit/Source candidates recruitment methods and channels recruiting activities/events recruitment vendors employee referral programs recruitment channels

      6.2.3.Screen and select candidates and deploy candidate selection tools candidates candidates and reject candidates

      6.2.4.Manage pre-placement verification candidate background information pre-employment screening recommend candidate

      6.2.5.Manage new hire/re-hire up and make offer offer candidate

      6.2.6.Manage Applicant Information applicant record applicant data and retain records of non-hires

    6.3.Develop and counsel employees

      6.3.1.Manage employee orientation and deployment employee on-boarding program new employees to managers workplace the effectiveness of employee on-boarding program onboarding program

      6.3.2.Manage employee performance performance objectives, appraise, and manage employee performance and review performance program

      6.3.3.Manage employee development competency management plans employee development guidelines employee career plans employee skills development

      6.3.4.Develop and train employees employee and organization development needs learning programs with competencies training needs by analysis of required and available skills, 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 salary/compensation structure and plan benefits and reward plan competitive analysis of benefit and rewards compensation requirements based on financial, benefits, and HR policies compensation and rewards to employees and motivate employees programs to support work/life balance for employees

      6.5.2.Manage and administer benefits employee benefits program benefit enrollment claims benefit reconciliation

      6.5.3.Manage employee assistance and retention family support systems retention and motivation indicators 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 employee communication plan employee suggestions and perform employee research employee communications

7.Manage Information Technology

    7.1.Manage the business of information technology

      7.1.1.Develop the enterprise IT strategy strategic intelligence long-term IT needs of the enterprise in collaboration with stakeholders strategic standards, guidelines, and principles and establish IT architecture and development standards strategic vendors for IT components IT governance organization and processes strategic plan to support business objectives

      7.1.2.Define the enterprise architecture the enterprise architecture definition enterprise architecture maintenance approach the relevance of the enterprise architecture as clearinghouse for IT research and innovation the enterprise architecture

      7.1.3.Manage the IT portfolio the IT portfolio and evaluate the value of the IT portfolio for the enterprise resources in accordance with strategic priorities

      7.1.4.Perform IT research and innovation technologies to innovate IT services and solutions viable technologies for IT services and solutions development

      7.1.5.Evaluate and communicate IT business value and performance and monitor key performance indicators IT plan performance IT value

    7.2.Develop and manage IT customer relationships

      7.2.1.Develop IT services and solutions strategy IT services and solutions to address business and user requirements business and user requirements into IT services and solutions requirements IT services and solutions strategic initiatives strategies with internal stakeholders to ensure alignment and select IT services and solutions strategic initiatives

      7.2.2.Develop and manage IT service levels and maintain the IT services and solutions catalog and maintain business and IT service-level agreements and report service-level attainment results business and IT service-level improvement opportunities

      7.2.3.Perform demand-side management (DSM) for IT services IT services and solutions consumption and usage and implement incentive programs that improve consumption efficiency volume/unit forecast for IT services and solutions

      7.2.4.Manage IT customer satisfaction and analyze customer satisfaction and communicate customer satisfaction patterns improvements based on customer satisfaction patterns

      7.2.5.Market IT services and solutions IT services and solutions marketing strategy and manage IT customer strategy IT services and solutions advertising and promotional campaigns 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 HIPAA Updates with clearing houses HIE updates platforms

      7.4.2.Perform provider informatics provider contracts provider/vendor performance provider quality analysis provider trends provider reporting standards

      7.4.3.Develop and maintain product informatics/reporting product performance quality analysis product utilization analysis product economics product demographics product portfolio distributions/contributions product risk indexes

      7.4.4.Perform membership analytics membership stratification membership analytics

      7.4.5.Set up membership accounts analytics service metrics analysis internal process metric analysis

      7.4.6.Develop information and content management strategies information and content management needs and the role of IT services for executing the business strategy the information and content management implications of new technologies and prioritize information and content management actions

      7.4.7.Define the enterprise information architecture information elements, composite structure, logical relationships and constraints, taxonomy, and derivation rules information access requirements data custodianship changes to content data architecture requirements

      7.4.8.Manage information resources the enterprise information/data policies and standards and implement data and content administration

      7.4.9.Perform enterprise data and content management sources and destinations of content data technical interfaces to users of content retention, revision, and retirement of enterprise information

    7.5.Develop and maintain information technology solutions

      7.5.1.Develop the IT development strategy sourcing strategy for IT development development processes, methodologies, and tools standards development methodologies and tools

      7.5.2.Perform IT services and solutions life cycle planning development of new requirements development of feature and functionality enhancement life cycle plan for IT services and solutions

      7.5.3.Develop and maintain IT services and solutions architecture IT services and solutions architecture IT services and solutions architecture IT services and solutions architecture

      7.5.4.Create IT services and solutions confirmed requirements IT services and solutions IT service/solution components services and solutions resources IT services/solutions customer acceptance

      7.5.5.Maintain IT services and solutions upkeep/enhance requirements and defect analysis change to existing IT service/solution changed IT service/solution component IT service/solution change solutions and services

    7.6.Deploy information technology solutions

      7.6.1.Develop the IT deployment strategy IT services and solutions change policies deployment process, procedures, and tools standards deployment methodologies and tools

      7.6.2.Plan and implement changes change deployment changes to stakeholders change schedule impacted users and install change change

      7.6.3.Plan and manage releases and coordinate release design and acceptance release rollout and install release release

    7.7.Deliver and support information technology services

      7.7.1.Develop IT services and solution delivery strategy sourcing strategy for IT delivery delivery processes, procedures, and tools standards delivery methodologies and tools

      7.7.2.Develop IT support strategy sourcing strategy for IT support IT support services

      7.7.3.Manage IT infrastructure resources IT inventory and assets IT resource capacity

      7.7.4.Manage IT infrastructure operations IT services and solutions IT operations support services

      7.7.5.Support IT services and solutions availability facilities backup/recovery performance and capacity incidents problems inquiries

8.Manage Financial Resources

    8.1.Perform planning and management accounting

      8.1.1.Perform planning/budgeting/forecasting and maintain budget policies and procedures periodic budgets and plans periodic financial forecasts

      8.1.2.Perform cost accounting and control inventory accounting cost of sales analysis product costing variance analysis on profitability

      8.1.3.Perform cost management key cost drivers cost drivers critical activities asset resource deployment and utilization

      8.1.4.Evaluate and manage financial performance customer and product profitability new products life cycle costing customer and product mix performance of new-customer and product strategies activity-based performance measures continuous cost improvement

    8.2.Perform revenue accounting

      8.2.1.Process customer credit credit policies new account applications existing accounts credit/collection reports or suspend accounts based on credit policies

      8.2.2.Invoice customer customer/product master files customer billing data billing data to customers receivable entries customer billing inquiries

      8.2.3.Process accounts receivable (AR) AR policies customer payments cash remittances AR reports AR activity to the general ledger

      8.2.4.Manage and process collections policies for delinquent accounts delinquent account balances with delinquent accounts account resolution with internal parties adjustments/write off balances

      8.2.5.Manage and process adjustments/deductions policies/procedures for adjustments adjustments with customer resolution with internal parties chargeback invoices related entries

      8.2.6.Manage and Process Risk Adjustments data related to Medicare and exchange business experience analysis with medical management clinical codes and documentation risk scores assumed in pricing updated information to CMS risk-score related adjustments with finance about payable/receivable and report CMS true-up

    8.3.Perform general accounting and reporting

      8.3.1.Manage policies and procedures service-level agreements accounting policies and enforce approval limits common financial systems

      8.3.2.Perform general accounting chart of accounts journal entries allocations period end adjustments (e.g., accruals and currency conversions) and reconcile intercompany transactions general ledger accounts consolidations and process eliminations trial balance and post management adjustments

      8.3.3.Perform fixed-asset accounting fixed-asset policies and procedures fixed-asset master data files and record fixed-asset additions and retires and record fixed-asset adjustments, enhancements, revaluations, and transfers and record fixed-asset maintenance and repair expenses and record depreciation expense fixed-asset ledger fixed-assets including physical inventory fixed-asset data to support tax, statutory, and regulatory reporting

      8.3.4.Perform financial reporting business unit financial statements consolidated financial statements business unit reporting/review management reports consolidated reporting/review of cost management reports statements for board review quarterly/annual filings and shareholder reports regulatory reports

    8.4.Manage fixed-asset project accounting

      8.4.1.Perform capital planning and project approval capital investment policies and procedures and approve capital expenditure plans and budgets and approve capital projects and fixed-asset acquisitions financial justification for project approval

      8.4.2.Perform capital project accounting project account codes project-related transactions and track capital projects and budget spending projects financial returns on completed capital projects

    8.5.Process payroll

      8.5.1.Report time policies and procedures and record employee time worked and report paid and unpaid leave regular, overtime, and other hours and report employee utilization

      8.5.2.Manage pay employee time worked into payroll system and administer employee earnings information and administer applicable deductions changes in tax status of employees and distribute payments and distribute manual checks period-end adjustments to employee payroll inquiries

      8.5.3.Process payroll taxes and pay applicable payroll taxes and distribute employee annual tax statements regulatory payroll tax forms

    8.6.Process accounts payable and expense reimbursements

      8.6.1.Process accounts payable (AP) AP pay file with purchase order vendor master file electronic commerce invoices and key data in AP system payments financial accruals and reversals taxes exceptions payments to AP inquiries records accounting records

      8.6.2.Process expense reimbursements and communicate expense reimbursement policies and approval limits and report relevant tax data reimbursements and advances reimbursements and advances personal accounts

    8.7.Perform liability and insurance reserve valuations

      8.7.1.Reconcile claim cash flows check register entries check register to cash flow invoices differences prior period membership eligibility-related adjustments prior period inter-company subrogation-related adjustments other top side adjustments

      8.7.2.Apply valuation standards claim data into required format data form and content business conditions, operating environment and other assumptions calculations per actuarial and regulatory standards and validate results for changes in business and/or operating environment results of analysis with management ledger entries to line of business and legal entity actuarial opinion by qualified actuary

      8.7.3.Manage reserving controls, policies and procedures scope and governance of reserve setting function and publish security and controls guidelines reserve setting protocols and responsibilities reserve setting and claim reconciliation procedures reserve setting procedures and update reserve and liability determination procedures for regulatory or controls related items and confirm internal controls system security requirements and permissions

    8.8.Manage treasury operations

      8.8.1.Manage treasury policies and procedures scope and governance of treasury operations and publish treasury policies treasury procedures treasury procedures treasury procedures treasury procedures and confirm internal controls for treasury system security requirements

      8.8.2.Manage cash and reconcile cash positions cash equivalents and oversee electronic fund transfers (EFTs) cash flow forecasts cash flows cash management accounting transactions and reports and oversee banking relationships, negotiate, resolve, and confirm bank fees

      8.8.3.Manage in-house bank accounts in-house bank accounts for subsidiaries and facilitate inter-company borrowing transactions centralized outgoing payments on behalf of subsidiaries central incoming payments on behalf of subsidiaries internal payments and netting transactions interest and fees for in-house bank accounts account statements for in-house bank accounts

      8.8.4.Manage debt and investment financial intermediary relationships liquidity issuer exposure and oversee debt and investment transactions and oversee foreign currency transactions debt and investment accounting transaction reports and oversee interest rate transactions reserves compliance

      8.8.5.Monitor and execute risk and hedging transactions interest-rate risk foreign-exchange risk exposure risk and execute hedging transactions and refine hedging positions hedge accounting transactions and reports credit

    8.9.Perform risk based capital and other solvency based reporting

      8.9.1.Collect required documentation and national association insurance commissioners guidelines update national association insurance commissioners guidelines procedures manual and tools data collection

      8.9.2.Compile documentation associated with each risk based capital component associated reported amounts within each risk based capital risk categories collection of documentation supporting each entry reported amounts and documentation

      8.9.3.Quantify risks in risk based capital formula and worksheets application of risk factors risk exposures against enterprise risk management risk appetites quantified risk amounts in models

      8.9.4.Validate calculations against regulatory updates collection of calculated amounts regulatory guidance and policies

      8.9.5.Perform sensitivity testing sensitivity tests and scenarios testing parameters with business owners sensitivity tests risk and sensitivity results 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 board of directors and audit committee and communicate code of ethics roles and responsibility for internal controls business process objectives and risks entity/unit risk tolerances

      8.10.2.Operate controls and monitor compliance with internal controls policies and procedures and implement control activities control effectiveness control deficiencies compliance function compliance function and maintain controls-related enabling technologies and tools

      8.10.3.Report on internal controls compliance to external auditors to regulators, share-/debt-holders, securities exchanges, etc. to third parties (e.g., business partners) to internal management

    8.11.Manage taxes

      8.11.1.Develop tax strategy and plan foreign, national, state, and local tax strategy and optimize total tax plan tax master data

      8.11.2.Process taxes tax planning/strategy returns foreign taxes deferred taxes for taxes tax compliance 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 cost trend projects

      8.13.2.Conduct actuarial informatics/reporting

      8.13.3.Manage experience rating pre-sale underwriting review claim experience premium

      8.13.4.Perform pool/block rating management with department of insurance rating methodology pool/block rates rating tools

      8.13.5.Conduct pool/block underwriting experience and history pool/block premium

      8.13.6.Provide underwriting support

      8.13.7.Manage regulatory requirements and compliance rate filing documentation information into state rating system(s) quality control testing on load rate load and internal system consistency rate assumptions and documentation 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 alignment of property requirements with business strategy the external environment build-or-buy decision

      9.1.2.Develop, construct, and modify sites

      9.1.3.Plan facility facility budget property terms for facility construction or modification to building

      9.1.4.Provide workspace and assets workspace and assets 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 people material and tools

    9.3.Obtain and install assets, equipment, and tools

      9.3.1.Develop ongoing maintenance policies for productive assets assets, and predict maintenance requirements approach to integrate preventive maintenance into production schedule

      9.3.2.Obtain and install equipment engineering solution for the manufacturing process 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 risk tolerance for organization and maintain enterprise risk policies and procedures and implement enterprise risk management tools the sharing of risk knowledge across the organization and report enterprise risk to executive management and board

      10.1.2.Oversee and coordinate enterprise risk management activities enterprise level risks risks to determine which to mitigate risk mitigation and management strategy, and integrate with existing performance management processes business unit and functional risk mitigation plans are implemented risks and risk mitigation actions are monitored on risk activities

      10.1.3.Coordinate business unit and functional risk management activities that each business unit / function follows the enterprise risk management process that each business unit/function follows the enterprise risk reporting process

      10.1.4.Manage business unit and function risk risks risks using enterprise risk framework policies and procedures mitigation plans for risks mitigation plans for risks risks risk activities and update plans on risk activities ORSA regulatory compliance process

    10.2.Manage compliance

      10.2.1.Establish compliance framework and policies enterprise compliance policies and procedures enterprise compliance activities internal audits controls-related technologies and tools

      10.2.2.Manage regulatory compliance regulatory compliance procedures applicable regulatory requirements the regulatory environment for changing or emerging regulations current compliance position, and identify weaknesses or shortfalls therein missing or stronger regulatory compliance controls and policies 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 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 capacity and size of investigation unit on pre-adjudication approach and technology on post-adjudication approach and technology on retrospective/post payment approach and recovery a vendor selection process anti-fraud and abuse solution

      10.5.2.Manage investigation unit and anti fraud and abuse operations program thresholds to match investigation unit capacity incoming claims to detect anomalies and suspicious patterns and prioritize transactions according to risk level and hold suspicious transactions for further investigation 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 and initiate compliance program compliance program

      11.4.5.Manage outside counsel problem and determine work requirements outside counsel if necessary strategy/budget work product and manage/monitor case and work performed payment for legal services legal activity/performance

      11.4.6.Protect intellectual property copyrights and patents intellectual property rights and restrictions licensing terms 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 and manage governance approach and maintain process tools and templates and support process ownership process governance activities

      12.1.2.Define and manage process frameworks and maintain process framework cross-functional processes

      12.1.3.Define processes processes processes processes processes

      12.1.4.Manage process performance process training process execution and report process performance

      12.1.5.Improve processes and select improvement opportunities improvement projects continuous improvement activities

    12.2.Manage portfolio, program, and project

      12.2.1.Manage portfolio portfolio strategy portfolio governance and control portfolio

      12.2.2.Manage programs program structure and approach program stakeholders and partners program execution and report program performance

      12.2.3.Manage projects project scope

 project requirements and objectives

 project resource requirements

 culture and readiness for project management approach

 appropriate project management methodologies

 business case and obtain funding

 project measures and indicators project plans

 roles and resources

 specific IT requirements

 training and communication plans

 recognition and reward approaches

 and plan launch of project

 the project projects

 impact of project management (strategy and projects) on measures and outcomes

 the status of project

 project scope

 and sustain activity and involvement

 and refresh project management strategy and approaches and report project performance projects

    12.3.Manage enterprise quality

      12.3.1.Establish quality requirements critical-to-quality characteristics preventive quality activities quality controls

 process steps for controls (or integration points)

 sampling plan

 measurement methods

 required competencies capability to assess compliance with requirements quality plan

      12.3.2.Evaluate performance to requirements against quality plan

 test and collect data


 disposition of result(s) results of tests

 sample significance



 next steps

      12.3.3.Manage non-conformance potential impact immediate action(s) root cause(s) corrective or preventative action non-conformance

      12.3.4.Implement and maintain the enterprise quality management system (EQMS) the quality strategy and deploy the EQMS scope, targets, and goals core EQMS processes, controls, and metrics and document EQMS policies, procedures, standards, and measures the EQMS performance environment and capability for EQMS improvement(s)

 quality excellence

 and maintain quality partnerships

 talent capabilities and competencies

 EQMS messaging into communication channels

 independent EQMS management access to appropriate authority in the organization

 proven EQMS methods

    12.4.Manage change

      12.4.1.Plan for change process improvement methodology readiness for change stakeholders champion design team scope current state future state organizational risk analysis

 cultural issues

 accountability for change management

 barriers to change

 change enablers

 resources and develop measures

      12.4.2.Design the change connection to other initiatives change management plans training plan communication plan rewards/incentives plan change adoption metrics new roles budget/roles

      12.4.3.Implement change commitment for improvement/change business processes and systems transition to new roles or exit strategies for incumbents change

      12.4.4.Sustain improvement improved process performance and reuse lessons learned from change process corrective action as necessary

    12.5.Develop and manage enterprise-wide knowledge management (KM) capability

      12.5.1.Develop KM strategy governance model central KM core group roles and accountability of core group versus operating units funding models links to key initiatives core KM methodologies IT needs and engage IT function training and communication plans change management approaches

 strategic measures and indicators

      12.5.2.Assess KM capabilities maturity of existing KM initiatives existing KM approaches gaps and needs existing KM approaches new KM approaches new KM approaches

      12.5.3.Identify and plan projects strategic opportunities to apply project management approach(es) process for knowledge sharing, capture, and use alignment with business goals

    12.6.Measure and benchmark

      12.6.1.Create and manage organizational performance strategy enterprise measurement systems model process productivity cost effectiveness staff efficiency cycle time

      12.6.2.Benchmark performance performance assessments benchmarking capabilities internal process and external competitive benchmarking gap analysis to understand need for change and degree needed need for change

    12.7.Manage environmental health and safety (EHS)

      12.7.1.Determine environmental health and safety impacts environmental impact of products, services, and operations health and safety and environmental audits

      12.7.2.Develop and execute functional EHS program regulatory and stakeholder requirements future risks and opportunities EHS policy and manage EHS events

      12.7.3.Train and educate functional employees EHS issues to stakeholders and provide support

      12.7.4.Monitor and manage functional EHS management program EHS costs and benefits and report EHS performance emergency response program pollution prevention program employees with EHS support


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