Covered California

Buyer seeks a consultant to perform an independent review of its Integrated Fraud Management (IFM) unit processes. The consultant will evaluate operational efficiency, enhance fraud prevention frameworks, and assess compliance with federal and state regulations. The project involves reviewing processes related to fraud detection, complaint handling, and data analytics tools. Buyer requires expertise in healthcare fraud, waste, and abuse management to improve its protection mechanisms for consumers and stakeholders.

• 5/30/2025 - RFP Release Date
• 6/9/2025 - RFP Questions Due
• 6/18/2025 - Responses to Questions Posted By
• 7/1/2025 - Proposal Due Date
• 7/21/2025 - Notice of Intent to Award
• 9/1/2025 - Anticipated Contract Term

• Ten years experience with consumer experience strategies and FWA knowledge
• Three years understanding healthcare industry's regulatory environment
• Three years in data analysis
• Three years working in the health care industry

• Review operational efficiency and effectiveness of fraud management processes
• Enhance and refine fraud management framework
• Model best practices for fraud detection and prevention
• Identify challenges and risks in current fraud management approach
• Review compliance with federal and state healthcare regulations
• Evaluate existing framework, policies, and procedures
• Compare IFM compliance with other state agency laws
• Analyze fraud detection and investigation workflows
• Assess data mining and predictive analytics tools
• Recommend improvements to complaint handling processes