The Experts Behind the Innovation @ HealthEdge: A Q&A Session with Mark Mucha

By Rob Duffy, CTO, HealthEdge

It’s easy to talk about innovation in healthcare technology; it’s harder to build it in a way that scales for health plans and improves real outcomes. At HealthEdge, we’re doing both. In this fireside-chat style Q&A, I sat down with Mark Mucha, our new Enterprise Architect at HealthEdge, to explore how his background, mindset, and day-to-day work fuel product innovation and modern engineering practices across our portfolio of solutions.

Rob: Let’s start with the basics: What does an enterprise architect at HealthEdge do?

Mark: It’s a newer title for me, and honestly, in this role, I wear a lot of hats. I participate in and run architecture reviews, offer guidance to teams, and, when it helps, I embed directly to write code or troubleshoot. I spend time on enablement—training and mentoring across our tech leadership group and the broader independent contributor (IC) community. I also pitch in wherever there’s a gap: coordinating with AWS on training rollouts, helping plan on-sites and off-sites, and joining early M&A conversations to understand how new capabilities could fit and add value. In short, I’m here to unblock teams and connect dots. Sometimes that’s a design decision, sometimes it’s hands-on help, and sometimes it’s just getting the right people together so we can move faster for our customers.

Rob: You’ve said before that “code never lies.” How do you ramp up so quickly on unfamiliar systems, and how does that translate to innovation for our customers?

Mark: I start with the source: read the code paths that matter, instrument what isn’t observable, and follow the data. Curiosity is the superpower here. I triangulate from multiple lenses, like unit tests, metrics dashboards, error logs, API contracts, even production traffic patterns, and build a mental model fast. That discipline uncovers truths about latency, reliability, and maintainability that conversations alone can miss. For health plans, that means we modernize carefully—keep what works, fix what doesn’t, and roll out well-tested changes in small but meaningful steps.

Rob: You shared with me a memorable line—you like to automate yourself out of a job. Where did that come from, and what does it mean inside HealthEdge?

Mark: The line comes from a very real moment early in my career. I was on a missile program at Lockheed Martin, and my task was to drive a GUI the same way, over and over, all day. It was mindnumbing and errorprone. On the first day, I thought there had to be a better way to do this. I put together a small automation that clicked through the workflow exactly the way the team needed, reliably and fast.

I thought that meant I could hand it off and move on to something more challenging. Instead, they decided to keep me on and have me automate more processes. That was the lesson: when you automate a painful process, you don’t make yourself irrelevant—you make the work better for everyone, and your responsibility shifts to improving and maintaining the new, cleaner path.

That mindset stayed with me. Whenever I’m working on something that I really don’t like, I force a new lens: how do we make this better—for me, for the team, for the next person who touches it? Sometimes the answer is automation; sometimes it’s changing the process. At HealthEdge, that shows up in cutting repetitive steps, writing down what works so others can reuse it, and creating simple paths so teams can focus on solving real-world problems for health plans.

Rob: You’ve also served in the military. How did that experience shape how you lead and build software?

Mark: The military gave me three things I still rely on every day: structure, mentorship, and camaraderie. Structure taught me to value clear goals and preparation. Mentorship showed me what good leadership looks like and why teaching is part of the job. And camaraderie—working in a team where people look out for each other sets the tone for how I show up at work. At HealthEdge, that translates to listening first, being dependable, and creating space for others to do their best work. When teams have clarity and trust, good software follows.

Rob: We talk a lot about bringing modern best practices into health insurance. What does that look like on the ground?

Mark: For me, it starts with people and purpose. I’ve always wanted my work to make a difference, and that shows up in small ways—like building educational video games with my daughter and paying attention to how real users learn. In our products, that translates to listening first, learning from the folks closest to the work, and removing friction they feel every day. I like environments where I’m empowered and can empower others—give teams clarity, trust them to execute, and create space to ask good questions. When we do that, the “best practices” take care of themselves: we tighten feedback loops, write down what we learn, and improve the experience one pragmatic step at a time. No heroics—just steady, human-centered progress that helps our customers and the members they serve.

Rob: Mentorship and community-building seem to be core to your approach. Why does that matter in a product organization like ours?

Mark: Innovation is a team sport. I host a monthly AMA so individual contributors have a direct line to technology leadership. The intent is simple: surface friction early, spot patterns across teams, and close the loop quickly. Mentorship is part coaching, part matchmaking—I don’t know everything, but I can connect people to the right partner or pattern. We invest in clear growth paths, study groups for certifications, and short, hands-on coaching sessions in the areas teams ask about most—observability, cost optimization, secure-by-default services, and FHIR workflows. Strong communities de-risk delivery because knowledge isn’t trapped; it moves.

Closing Thoughts 

Spending time with Mark is a reminder of what makes HealthEdge special: builders who pair humility with high standards, and who care as much about people as they do about systems. Mark brings that mix every day—and he’s part of a broader, cross-functional team of experts that spans the entire HealthEdge portfolio. Architects, product managers, SREs, clinicians, data scientists, designers—seasoned veterans working shouldertoshoulder with phenomenal new teammates who’ve recently joined us from across healthcare and enterprise technology backgrounds.

Driving AI Transformation Through Strategic Learning: HealthEdge’s Multi-Channel Approach 

At HealthEdge, we know that deploying AI tools is just one piece of the puzzle. True transformation happens when people across the organization not only understand what AI can do but also begin to apply it in ways that elevate their day-to-day work. That belief has guided our approach to learning and development as we scale AI adoption.

Our teams span a wide range of roles from claims analysts and care managers to product leads and engineers. That diversity requires a learning strategy that can meet people where they are, whether they’re just beginning their AI journey or already building solutions. To help make that happen, we’ve built a multi-channel learning ecosystem that combines centralized resources, live expert-led sessions, self-paced development, community interaction, and continuous feedback.

Multi-Channel Learning Modalities

The AI Hub: Centralizing Knowledge Resources: We established a centralized AI Hub on the HealthEdge intranet platform, serving as the single source of truth for AI learning resources. This hub houses curated content, including top AI podcasts, recommended books, instructional videos, and manager-specific resources. The platform also features structured AI learning paths and houses recordings from various AI sessions, ensuring that learning resources remain accessible beyond live events.

The centralization strategy addressed a critical challenge identified in employee feedback: the proliferation of scattered resources across different platforms. By consolidating everything in the AI Hub, we eliminated the friction that often prevents employees from engaging with learning content.

AI Power Hours: Sharing The Learning: The monthly AI Power Hour sessions became a cornerstone of the HealthEdge learning strategy, featuring both internal experts and external speakers. These hour-long sessions cover topics ranging from fundamental AI concepts to specific tool demonstrations, with notable speakers including company leaders and external technology partners.

The program has demonstrated strong engagement across the organization. So far in 2025, 36% of people managers and 30% of all employees have attended at least one AI-specific Power Hour session. Attendance peaked at 380 participants in January 2025 for “AI Innovation in Action,” a session on practical AI applications led by CTO Rob Duffy, indicating high organizational interest.

Recognizing diverse learning needs, we plan to implement a dual-track approach: technical sessions focused on specific tools and implementation for engineering teams, and enterprise-wide sessions covering topics like prompt engineering that apply across all roles.

LinkedIn Learning: Self-Paced Professional Development

We leveraged our existing LinkedIn Learning platform investment to provide comprehensive, self-paced AI education. This modality has been growing in popularity: by mid-2025, we had already approached 2024’s full-year AI learning consumption levels. Employees are not just consuming content broadly through individual courses (903 started in 2025) but also focusing on deeper programs through structured learning paths (122 started in 2025).

Business unit analysis shows particularly strong engagement from technical teams, with our Tech organization leading in both learning path and individual course consumption. However, significant adoption across the HealthRules® Payer (58 learning paths started) and Global Professional Services (15 learning paths started) business units demonstrates that AI learning extends well beyond traditional technology roles.

Community Engagement: More Ways To Get Involved

We expanded our learning ecosystem with several supporting initiatives. The “AI @ HealthEdge” Teams channel provides a platform for peer-to-peer learning, questions, and sharing of AI innovations. Monthly “Ask Me Anything” sessions with leadership create opportunities for real-time problem-solving and guidance.

The global nature of our workforce is reflected in specialized programming, including monthly AI Talk sessions hosted by our team in India, ensuring that learning resources serve all geographic regions and time zones.

Pulse Surveys: Measuring Transformation Progress

To measure success, HealthEdge implements quarterly pulse surveys tracking AI transformation progress across six key dimensions. These surveys provide crucial feedback on the effectiveness of learning initiatives and identify areas requiring additional focus.

Our comprehensive learning approach has yielded significant measurable improvements across all tracked dimensions. Between Fall 2024 and Summer 2025, we saw improvements in every survey category:

  • AI familiarity and role application: Increased from 71% to 81%
  • Adequate information/training: Rose from 59% to 66%
  • Easy access to AI resources: Improved from 61% to 68%
  • Leadership support: Strengthened from 82% to 88%
  • Empowerment to recommend AI solutions: Grew from 66% to 76%
  • Belief in AI’s positive company impact: Increased from 76% to 81%

While these improvements are encouraging, we recognize that scores in the low-to-mid 60s for training adequacy and resource access indicate continued opportunity for enhancement. The partnership between these two teams specifically targets these areas through more hands-on enablement and practical application training.

Looking Forward: Sustainable AI Transformation

Our multi-channel learning approach demonstrates that successful AI transformation requires more than technology implementation. It demands thoughtful change management that meets diverse learning needs while maintaining focus on practical application.

The learning ecosystem has successfully shifted organizational sentiment from AI apprehension to enthusiasm. As Wendi Ellis, our VP of Talent and Learning, noted in team discussions, the focus has evolved from making employees “not afraid” of AI to driving actual adoption and practical application.

By combining centralized resources, live community learning, self-paced professional development, and continuous feedback loops, we’re building the foundation for sustainable AI adoption that drives real business value.

Why This Matters

For AI to be truly transformational, it must be accessible. That means investing in both learning and tools. Our approach is built around the understanding that no single learning method fits all. A product owner needs something different than a care manager, and a developer learns differently from a sales lead. Multi-channel learning lets us respect those differences while unifying our organization around a common goal: using AI to drive smarter decisions and better outcomes. We’re encouraged by the momentum and even more excited about where this can go.

Regulatory & Compliance Q&A: How the OBBBA Could Impact Care Management & Member Engagement

On June 10, 2025, the One Big Beautiful Bill Act (OBBBA), also known as H.R.1, was signed into law, marking the beginning of one of the most sweeping healthcare reforms in recent memory. Given the scope and future impact on regulatory requirements, health plans must closely assess their agility to adapt their business models as well as their digital solutions. Not only must health plans adjust to the increased scrutiny of eligibility validation and expanded scope of government program audits, but also strengthen their adaptability to the downstream impacts of H.R.1 in the years to come.

We sat down with Jennifer Vicknair, RN, MBA, Senior Director of Regulatory, Accreditation and Compliance at HealthEdge®, to discuss how the OBBBA is reshaping state regulations and why regulatory compliance agility is imperative for long-term success.

What are you seeing and hearing so far as the most significant impacts of the OBBBA on health plans?

Vicknair: The most immediate pressure for health plans is changes to Medicaid eligibility validation and waiver programs. Many payers still rely on outdated or highly manual processes and technologies that can’t keep up. Plan leaders are concerned about the rapid pace of change, how to effectively communicate these changes to their internal teams, and the administrative costs of audit readiness.

OBBBA’s impact will exponentially increase complexity at the state level. While the federal laws broadly align regulatory and enforcement governance, each state will respond with specific guidance applicable to their own eligibility rules, benefit structures, and reporting requirements. That means a plan operating across multiple states could be managing an entirely different compliance need in each state. If a plan lacks the technological capabilities to configure benefits and services quickly, the risk of exposure during audits can lead to penalties, sanctions, or exclusions from government programs.

The downstream effects will directly impact the health plan’s quality, population health, and care management programs. Complexity of eligibility and enrollment workflows will necessitate a shift of resources to minimize interruption in coverage. Quality initiatives will lose valuable data points that have been historically used to influence how the plans move the needle on population health. Care management and member engagement solutions play a vital role by giving care teams access to up-to-date information, eligibility, and waiver usage. Real-time information allows care teams to coordinate care effectively, even as regulatory requirements continue to change.

What does “regulatory compliance agility” mean under OBBBA or other such broad changes to healthcare?

Vicknair: Regulatory compliance agility means having prompt regulatory change management. Health plans must partner with technology vendors to operationalize new requirements quickly without months of custom coding. As states issue guidance, audit scrutiny will intensify, and regulatory agencies will begin enforcement activities. Health plans need visibility into their technology ecosystem to proactively address changes, rather than responding retroactively.

Health plans need to partner with technology vendors who provide best-practice workflows and recommended configurations. Technology vendors should support continuous audit readiness by meeting health plan needs for operational controls, traceability, and reporting—and that’s why having integrated care management and member engagement solutions is so valuable.

With HealthEdge GuidingCare® and Wellframe™, health plans can unify clinical data with member engagement. The solutions help surface gaps in care and align clinical resources from health plans and community partners to meet the member’s needs holistically.

It also comes down to partnerships. Technology vendors must demonstrate more than technical capability. Vendors need expertise in Medicare and Medicaid and need to understand the nuance of specific programs like Dual-eligible Special Needs Plans (DSNPs) and Long-Term Services and Supports (LTSS).

A strong technology partner anticipates potential impacts of regulatory change on the health plan and supports the plan’s compliance with appropriate product enhancements. Vendors with strong change management leadership can supplement the efforts of the health plan through cross-functional collaboration. Through strong vendor collaboration, regulatory agility can be the health plan’s ongoing stance for regulatory readiness through implementation and operationalization.

What do you see as the biggest challenges health plans will face as they adapt to OBBBA?

Vicknair: One is the coordination of cross-functional health plan response. Regulations, rules, and guidance often come to health plans sporadically and in dense non-prescriptive language. Translating that into technical requirements or operational workflows isn’t always straightforward. Clinical and care management requirements can be especially vague when considering the expertise required to connect disparate systems and processes to promote quality of care. Resources may be further limited by growing pressure to reduce operational expenses.

Risks of provider disruption and abrasion happen when changes to eligibility and coverage are inconsistent because of near-constant change. For example, if a rural care facility closes, the health plan faces an influx of care coordination, network adequacy, and member access needs. Care management systems like GuidingCare can help by allowing health plan leadership to monitor impacts on population health and track real-time efforts to close gaps in care. At the same time, rural provider disruption reinforces the importance of digital member engagement. Wellframe allows payers to maintain consistent connection between members and care teams. Health plans can provide guidance and support even when local providers may be harder to reach.

Another challenge is OBBBA’s impact on Medicaid funding. Health plans will need to do more with fewer resources. Waiver programs have new budget neutrality requirements which will force plans to demonstrate mechanisms for delivering cost-effective care. Eligibility restrictions will lower federal reimbursement for essential programs that have been proven to improve outcomes. Increased administrative burden coupled with unique needs of Medicaid populations creates risk for compliance, clinical outcomes and population health.

Finally, audit pressure has increased in recent years. OBBBA will refocus regulatory scrutiny because of the expansion of regulatory scope, governance and authority. Regulators are ramping up oversight activities, and health plans that can’t clearly demonstrate compliance with accurate, traceable data and workflows are at risk. Payers need to act now by assessing configurations, documenting workflows, identifying gaps, and validating audit-readiness. Government programs should prioritize avoiding civil and monetary penalties, sanctions, or exclusions—not only to stabilize revenue but to safeguard market growth opportunities.

How should health plans think about technology investments to prepare for OBBBA?

Vicknair: Technology that supports regulatory compliance agility is the priority. Health plans need platforms that support rapid regulatory change management functionality including real-time eligibility validation and clinical outcome tracking. These capabilities reduce compliance risk and lower cost of care.

Integration and interoperability are becoming increasingly important. Most health plans operate in siloed organizational structures and use disconnected systems. OBBBA will encourage plans to coordinate eligibility, clinical, and claims data to enable faster internal decision-making. Affordability and clinical outcome data then become essential for yearly plan benefit design, Model of Care (MOC) submissions and market expansion initiatives.

Finally, payers should look for systems that support population health management. Equipping care teams with tools to assess and manage members at scale allows health plans to address medical and social health risks, close care gaps, and improve outcomes. The health plan’s clinical leadership can then monitor population-specific data to ensure day-to-day work aligns with clinical quality initiatives.

GuidingCare provides care teams with a comprehensive view of member needs and supports personalized care plans that help members reach their health and wellness goals. The Wellframe also helps care teams foster meaningful connections with members. Together, GuidingCare and Wellframe enable health plans to adapt population health strategies quickly, even in a resource-constrained environment.

How does OBBBA reshape the conversation around population health and member engagement?

Vicknair: Ultimately, OBBBA reinforces the need for cost-effective care through measurable outcomes and validated performance metrics. Health plans must manage members more efficiently. Clinical quality standards coupled with growing value-based care initiatives will strengthen health plans’ need for comprehensive care management. Addressing non-clinical social needs, behavioral health needs, and traditional medical needs will balance reliability of outcomes.

Another significant factor for health plans is the shift in care management caseloads. OBBBA will drastically reduce health plan federally funded reimbursement, which will inherently lead to care teams having a higher nurse-to-member ratio. And, non-clinical care team members will see an expansion in responsibility, as their scope of practice allows. Care teams will have to capitalize on technology efficiencies to positively impact population health outcomes. Scalable member engagement becomes essential.

By offering a mobile app for health plan members, Wellframe ensures engagement is timely, personal, and accessible. Health plans don’t have to wonder if members receive physical mail or wait for pre-scheduled and long-format phone calls to share information. The Wellframe app includes personalized checklists with medication, activity, and appointment reminders. Members can also send direct messages to their care teams through a HIPAA-compliant chat function, and access educational articles that answer common and relevant health questions—empowering members and improving health literacy.

The combination of Wellframe and GuidingCare capabilities supports care teams and members in making better-informed care decisions in less time. Effective population health management is essential for health plan growth post-OBBBA, and health plans should prioritize technology that supports improving medical loss ratios, lowering operational expenses and administrative costs, and protecting reimbursement.

Looking ahead, what advice would you offer to health plans as they prepare?

Vicknair: Don’t wait for perfect clarity. The regulatory landscape will continue to evolve. The best strategy is to invest in technology and vendor partnerships that can adapt to anticipated changes, so payers build agility into their systems and processes proactively.

Take a proactive stance. Educate your teams, model different scenarios, and ensure audit readiness before an audit is imminent. Promote internally that that OBBBA is an opportunity to modernize infrastructure that aligns with government program priorities and allows efficiency gains across the health plan ecosystem.

Are you looking for a strategic framework to help your health plan adjust to rapidly evolving regulations? Read our blog, A Strategic Framework to Navigate the One Big Beautiful Bill Act.

A Strategic Framework to Navigate the One Big Beautiful Bill Act

Sweeping policy changes are nothing new in U.S. healthcare, but the One Big Beautiful Bill Act (OBBBA), also known as H.R. 1, represents a particularly consequential inflection point for health plans. With provisions that alter funding, tighten eligibility, and enhance accountability for administrative efficiency, OBBBA challenges payers to rethink their operations.

The impact extends beyond compliance. It disrupts long-standing operating models, accelerates the need for modernization, and exposes the hidden inefficiencies that have accumulated across payer ecosystems. However, amid the turbulence lies opportunity: health plans that act decisively can strengthen operational resilience, improve member engagement, and reduce the cost of care.

In this executive framework, we explore three imperatives that can help payers turn disruption into a strategic advantage:

  1. Consolidate vendors to reduce cost and complexity
  2. Automate workflows to enhance agility and ensure compliance
  3. Engage members to drive satisfaction and retention

Together, these focus areas form the foundation for a leaner, smarter, and more connected health plan, one positioned to thrive in the post-OBBBA era.

1. The Case for Digital Consolidation: Simplifying Vendor Sprawl

For years, payers built their digital ecosystems piece by piece, adding point solutions for care management, utilization management, member outreach, health education, and engagement. The result is vendor sprawl: a tangle of platforms, contracts, and integrations that can drive up costs and dilute the member experience.

A 2025 PwC Health Research Institute report found that 62% of payer executives cite “too many disconnected point solutions” as a top barrier to operational efficiency and cost containment. The financial implications are real: redundant vendor contracts, increased administrative oversight burden, and fragmented data flows add millions in avoidable administrative costs annually.

Under OBBBA, this fragmentation becomes untenable. Health plans must process eligibility changes in real time, comply with new data reporting mandates, and deliver consistent and cost-effective care management, all of which require unified systems.

Forward-thinking payers are now consolidating member-facing functions under a single digital engagement layer. These platforms combine care management, health education, secure communication, and outreach, creating a continuous experience for both members and care teams.

Digital engagement platforms such as HealthEdge Wellframe™ exemplify this consolidation trend. Health plans can leverage these solutions to strengthen both care coordination and member trust.

The result? Lower administrative burden, improved efficiency across functions, and a more consistent experience for members are all essential differentiators as OBBBA reshapes market dynamics.

2. Automate to Adapt: Building Resilience Through Workflow Intelligence

OBBBA introduces new administrative complexity, particularly for Medicaid and Affordable Care Act (ACA) exchange plans. More frequent redeterminations, evolving eligibility requirements, and expanded reporting obligations are driving unprecedented increases in administrative tasks. For health plan executives, this means scaling operations without sacrificing accuracy or compliance.

Manual processes can no longer meet these demands. Workflow automation has become a core operational necessity, enabling payers to process more work with fewer errors, enforce consistency, and redirect staff toward higher-value activities. According to the HealthEdge Annual Payer Market Planning Report, most health plan executives are prioritizing technology modernization and automation to reduce administrative costs and strengthen compliance. This shift signals that automation is no longer viewed as a technology project—it’s a business continuity strategy.

For health plans, intelligent automation can:

  • Streamline operational workflows such as prior authorization processing, eligibility verification, and scalable member outreach.
  • Orchestrate interdepartmental coordination, ensuring clinical teams, member services, and operations staff act on the same data in real time.
  • Reduce administrative overhead by eliminating redundant touchpoints between legacy systems.
  • Enhance audit readiness through standardized documentation and digital traceability.

Wellframe automates member engagement and care management functions, triggering clinical risk alerts, population outreach, and enabling care teams to engage members more efficiently. A successful strategy must consider the entire health plan landscape: under OBBBA, automation is about giving care teams the intelligence and structure they need to act faster, maintain compliance, and operate with agility in an environment defined by constant change.

3. Member Engagement: The Retention Imperative

Perhaps the most visible and risky impact of OBBBA lies in member churn. As eligibility becomes stricter and redetermination cycles intensify, millions of individuals may move in and out of coverage more frequently. For payers, every lost member represents not just lost revenue but also increased acquisition costs and disrupted continuity of care.

Member engagement, once viewed primarily as a satisfaction metric, has evolved into a financial and strategic necessity. Retaining members reduces the impact of volatile eligibility and stabilizes government program reimbursement.

Leading plans are adopting mobile-first engagement models that combine personalized education, push notifications, and two-way messaging to keep members informed and connected. These approaches not only build trust but also drive measurable improvements in retention.

A recent HealthEdge Wellframe case study demonstrated that when a regional Blue Cross Blue Shield plan implemented Wellframe’s digital engagement platform, its care teams achieved a 91% increase in successful member outreach calls and six times more member interactions than traditional methods. These outcomes highlight how digital engagement can expand reach, strengthen relationships, and sustain continuous communication with members.

In short, engagement is the connective tissue that links eligibility, satisfaction, and retention in a post-OBBBA environment.

A New Operating Blueprint for Payers in the OBBBA Era

The One Big Beautiful Bill Act is reshaping the payer landscape in ways that demand greater agility, integration, and accountability. Health plans that remain dependent on fragmented systems and manual processes will struggle to meet new operational and regulatory expectations. To stay ahead, payers must adopt a unified model, one that integrates data, teams, and member experiences across the entire enterprise.

Digital platforms like Wellframe demonstrate how that model can come to life in practice, helping health plans streamline operations, automate intelligently, and deliver more connected member experiences that improve satisfaction and retention.

By bringing engagement, education, and care management into a single digital platform, Wellframe enables payers to reduce administrative overhead, enhance staff productivity, and strengthen member relationships. The result is a more efficient and resilient organization, one equipped to meet the demands of OBBBA today while advancing long-term goals for growth, value, and member trust.

Learn more about how your health plan can meet evolving member expectations with member engagement and care management solutions. Watch the webinar on-demand: “Navigating Digital Care Management Transformation: Delivering on Consumer Expectations with Effective Change Management.”

Modernizing Tech-Enabled Services to Become Tech-Enabled Solutions 

Health plans are under increasing pressure to modernize operations while managing rising costs, regulatory complexity, and evolving member expectations. Many have adopted tech-enabled services to address specific pain points—like claims processing, enrollment, customer service—but these are disparate services that often operate in silos, increasing the risk of fragmentation and inefficiency.

The next evolution is here: tech-enabled solutions. Business Process as a Service (BPaaS) represents a unified, scalable model that integrates technology, operations, and accountability into a single framework. It’s not just about outsourcing tasks—it’s about transforming how health plans operate.

The Problem: Fragmentation in a Digital World

Despite widespread adoption of digital tools, many health plans still struggle with:

  • Disparate systems and vendors
  • Manual interventions and data silos
  • Limited scalability and oversight
  • Rising administrative costs

These challenges are compounded by cybersecurity risks, the demands of value-based care, and the need for real-time responsiveness.

The Shift: From Services to Solutions

Tech-enabled services solve isolated problems. Tech-enabled solutions solve systemic ones.

BPaaS is the embodiment of this shift. It consolidates platform, operations, and vendor accountability into a single, outcome-driven solution. This model enables health plans to move beyond tactical fixes and embrace strategic transformation.

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What truly distinguishes BPaaS is its unwavering focus on agility and outcomes.

BPaaS Platform: The Engine of Agility

At the heart of BPaaS is a modular, cloud-based platform that supports automation, interoperability, and real-time execution. Whether through systems of record or engagement, it delivers stable run rates, built-in maintenance, and flexible pricing models.

Operations: Expertise Embedded in Technology

BPaaS integrates business processes with application workflows, embedding healthcare-specific knowledge into every layer. This ensures compliance, drives efficiency, and aligns operations with industry best practices.

Unified Contractual Framework

A single contract governs both technology and services, streamlining vendor management and ensuring accountability—even when third-party tools are involved. This simplifies oversight and enhances transparency.

Strategic Advantages of BPaaS for Health Plans

Simplified Oversight

With one vendor managing the full ecosystem, health plans gain centralized visibility and control. This reduces operational risk and accelerates decision-making.

Cost Efficiency

BPaaS eliminates the overhead of managing multiple vendors and systems. Fewer manual processes mean lower operating costs and reduced total cost of ownership.

Agility in a Changing Landscape

BPaaS enables rapid adaptation to regulatory updates, member needs, and market shifts. This agility is a strategic advantage in a dynamic healthcare environment.

Member-Centric Outcomes

Streamlined processes lead to faster claims, smoother enrollment, and better service. The efficiency gains can be reinvested into member-focused initiatives, improving satisfaction and loyalty.

From Tactical to Transformational

Tech-enabled services were a step forward. Tech-enabled solutions are a leap. BPaaS empowers health plans to move beyond fragmented fixes and embrace a unified, strategic operating model. It’s not just about doing things better—it’s about doing better things.

At HealthEdge®, we help health plans assess their needs and chart a path forward. We would love to hear more about your organization’s goals and challenges.

Learn more about the power of tech-enabled solutions in the case study: “Fixing the Foundation”.

Reimagining Work @ HealthEdge: How AI is Transforming the Way We Build, Support, and Deliver 

At HealthEdge, AI is becoming a foundational capability that’s changing how we operate from the inside out.

In this fireside chat, I had the opportunity to sit down with @Andrew Witkowski, who leads our AI Team, to discuss what it truly means to become an AI-first enterprise. We explored how this shift goes beyond tooling to change the shape of work, the speed of innovation, and the experience of every team member and customer.

Rob: Let’s start with the big picture. What does it mean for HealthEdge to become an AI-first company?

Andrew: For us, AI-first means rethinking work at every level, not just layering automation onto existing processes. We’re using AI to fundamentally redesign how teams operate, where time is spent, and how decisions get made. It’s not about replacing people. It’s about empowering them. If AI can handle repetitive or manual work, our teams can spend more time solving complex problems, collaborating, and delivering value to customers faster.

We’re treating AI with the same seriousness we applied to our cloud transformation, which is full governance, intentional design, and alignment with our business strategy.

Rob: You’ve built a new program to support this transformation called the Workforce Transformation Lab. What does that team do, and how does it work?

Andrew: Think of the Lab as a hands-on innovation partner. We embed ourselves with teams across the company, from engineering and customer support to product and finance, to help them rethink their workflows. We partner with teams in one week long intensive Idea-to-Impact sprint, in which we systematically evaluate all the work they’re doing and prototype an AI solution that addresses their repeated, routine work. We ask: What should be done entirely by humans? What can be accelerated by AI? And what can be fully replaced? These experiments let us validate before we scale.

This isn’t just about efficiency. It’s about enabling team members to focus on higher-value tasks while building the literacy necessary for broader success.

We use a framework we call the “4 Rs”:

  • Retain work where human judgment is critical
  • Reassign work to more strategic roles
  • Refactor processes to make them more AI-compatible
  • Replace work entirely where AI can do it faster, with clear SLAs and fallback options

Refactoring, in particular, is where we see the biggest opportunity. This is where AI delivers the most value, not by removing humans from the loop, but by redesigning workflows so people stay in control while AI handles the repetitive heavy lifting. In healthcare technology, this balance is critical. And it fundamentally changes how people approach their work, freeing them to focus on judgment calls and edge cases while maintaining the oversight our industry demands.

Rob: How has this shift changed the way we develop software?

Andrew: The difference is night and day. We’re building what we call an “agentic factory,” a development environment where AI agents assist throughout the lifecycle: requirements gathering, test generation, documentation, and even deployment validation.

Where Agile was about delivering in two-week increments, AI enables us to prototype, test, and refine in hours or even minutes. It’s a shift in the constraint from execution to creativity and quality of judgment.

And it helps resolve one of developers’ biggest frustrations: blockers. AI reduces wait time for everything, including access, reviews, and approvals. That frees people up to focus on the creative and satisfying parts of the job.

Rob: What does this mean for HealthEdge customers?

Andrew: A lot. Our internal transformation directly benefits the plans we serve. Faster release cycles, smarter product features, and more aligned solutions across HealthRules® Payer, GuidingCare®, and HealthEdge Source™. The same AI-powered tools that help us internally are showing up in our products, with things like natural language understanding, enhanced analytics, and adaptive workflows.

It’s more than an efficiency play. It’s about creating solutions that are more intelligent, more responsive, and more tailored to how health plans actually operate.

Rob: AI can sometimes feel like it’s all about the tech. But you’ve emphasized the people side of this transformation. Can you talk more about that?

Andrew: Cultural transformation is one of the hardest parts of AI adoption. Our early success came from creating a space of psychological safety where people felt free to question the status quo and experiment.

We’re hiring people who can collaborate with AI, and we’re ensuring teams use AI before opening new roles. We’re also evolving our development standards and using AI support at every stage: testing, code reviews, and documentation.

At the role level, we’re seeing developers become AI-enabled problem solvers. QA professionals are becoming quality strategists. AI is changing how we work, and we’re helping people define their next chapter.

That can be scary for some, especially if you’re comfortable and confident in a particular workflow. That’s why transparency and trust are essential. We want people to feel supported, not sidelined. We’re making big investments in upskilling and development to ensure every employee becomes an AI-augmented contributor.

Rob: What’s next on the horizon?

Andrew: We’re focused on three things for the second half of 2025:

  1. Scaling pilot success. We’ve seen great results, and now we’re formalizing strategy across the business.
  2. Launching our internal AI platform. This suite of tools will integrate with the toolkits employees already use, meeting them where they are.
  3. Embedding AI into our customer products. We’re actively running workshops with customers to understand what they want from AI. There’s a lot of excitement, and we want to deliver real value in the HealthEdge portfolio.

Closing Thoughts

Spending time with Andrew reinforces what makes HealthEdge different: a deep commitment to innovation, paired with a people-first mindset. We’re not chasing AI for hype. We’re building it into the way we work, which is thoughtfully, pragmatically, and in service of better outcomes for our customers and their members.