Case Study: a large urban-based health plan company transforms care and operations with HealthEdge

Health Plan for Large Metropolitan Area Transforms Care and Operations with HealthEdge® Solutions

A large urban-based health plan company faced significant growth challenges due to an outdated core claims processing system, which was being sunset by its vendor, and inefficient manual processes. The plan, operating numerous government-sponsored programs, needed a modern, integrated solution to reduce its IT burden, automate operations, and meet unique state care management requirements. They selected an integrated solution from HealthEdge, comprising the HealthRules Payer core administrative system and the GuidingCare care management platform.

HealthEdge implemented its natively integrated solutions to provide a complete view of each member's journey and automate key processes. The HealthRules Payer system offered the flexibility and automation needed to increase auto-adjudication and payment accuracy rates, while GuidingCare provided the robust, certified capabilities required for state compliance and managing complex care needs. This modern SaaS platform relieved the IT burden and equipped the health plan to operate more efficiently while supporting its rapidly expanding membership across all 11 lines of business.