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When health plans modernize their core administrative systems, the conversation often centers on technology. Implementation timelines, configuration decisions, and integrations dominate planning discussions as organizations prepare for go-live.

Yet one of the biggest factors determining whether a new platform delivers meaningful operational improvements has little to do with the technology itself. According to research from McKinsey & Company, successful transformations are more than three times more likely when organizations provide dedicated training to help employees master new solutions.

It comes down to whether the people responsible for running the system understand how to use it.

Leveraging Education Services for Product Training

For health plans implementing HealthRules® Payer, training is critical to ensuring the platform operates as intended and that operational teams can fully leverage its automation capabilities. Without that foundation, even the most advanced technology can struggle to deliver the expected improvements in efficiency and accuracy. In fact, any team member who supports implementation, serves as an in-house instructor, or uses the system on a day-to-day basis should receive training.

That is why HealthEdge® Global Professional Services provides dedicated Education Services designed to help health plans build the expertise needed to successfully implement and optimize HealthRules Payer.

HealthEdge Education Services Overview

HealthEdge offers a comprehensive suite of training programs, tailored to every stage of implementation and beyond. The programs support both technical and business teams and are designed to empower a health plan’s in-house training team to confidently educate those responsible for implementing and using the system every day. There’s even an opportunity for implementation partners to participate in structured certification programs that ensure consistent expertise, best-practice alignment, and a higher standard of delivery across the ecosystem.

The Real Costs of Insufficient Training: Internal Misalignment

Health plans are often under strict time constraints when implementing a new administrative platform. Internal leaders participate in discovery workshops, design sessions, and configuration reviews while continuing to manage their day-to-day responsibilities.

In this environment, training can easily be deprioritized—but the consequences typically appear quickly once the system is in production, where small misunderstandings can create operational friction.

For example, terminology differences between legacy systems and HealthRules Payer can cause confusion early in the transition. A “provider” label in one system may appear as “supplier” in another. While the difference may seem minor, misalignments like these can interfere with understanding system data and configuring workflows.

Unnecessary Manual Intervention

Training gaps can also lead to complications like improper or incomplete user setup, which can result in increased manual intervention during claims processing and lower automation levels across the platform. Teams may also overlook powerful capabilities and miss out on opportunities to simplify operations.

For example, if a health plan experiences a retroactive member termination, the system should trigger automatic claim reprocessing. If users don’t know HealthRules Payer can automate this process, they may spend unnecessary time on manual review.

Without proper attention to product training, users may rely on workarounds or manual processes that the platform was designed to eliminate.

Building Knowledge Throughout the Implementation Journey

HealthEdge Education Services are designed to enable business and technical users who support the implementation throughout the HealthRules Payer deployment lifecycle.

Rather than treating training as a one-time activity, programs align with the natural phases of implementation—starting with foundational education of key concepts and terminology. Training becomes more hands-on as the project progresses into design and build phases, allowing internal subject matter experts to gradually build knowledge while applying what they learn directly to the configuration of their system.

Self-guided learning modules also provide an introduction to core platform capabilities. Instructor-led training sessions then give teams the opportunity to work directly within the system, ask questions, and explore real-world scenarios that reflect their organization’s operational workflows. Coaching sessions are also available to help reinforce learning by allowing participants to bring questions that come after working in the system.

Preparing End Users for Day-to-Day Operations

One of the most important aspects of system training occurs as organizations prepare for go-live.

In many implementations, the people configuring the platform are not the same ones who will use it every day. Claims processors, enrollment teams, and finance staff may interact with the system differently from the implementation team that helped design it. To address this challenge, Education Services leads End User Enablement workshops to assist in-house trainers as they develop their own internal programs.

During these dedicated workshops, HealthEdge trainers work closely with a health plan’s in-house instructors to develop training materials tailored to the organization’s configuration and operational workflows. Templates and guidance from the HealthEdge team help health plan teams build the training materials for their operational staff.

This approach helps ensure end users learn workflows as they exist in their unique environment. It also helps operational teams understand how their day-to-day processes will evolve as they transition from legacy workflows to the automated capabilities available in HealthRules Payer.

Why Training Matters Long After Go-Live

The importance of training does not end once the system launches.

As health plans expand their use of HealthRules Payer, introduce new benefit designs, or refine operational workflows, new training needs often emerge. Organizations frequently return for focused refresher training that target areas where teams request additional support.

Education Services works closely with customers to understand where knowledge gaps exist. The training team may collaborate with delivery managers or implementation consultants to understand the payer’s unique challenges to tailor the sessions.

This collaborative approach allows health plans to strengthen internal expertise, improve operational efficiency, and reduce reliance on external consulting resources over time.

Modernizing Training With AI-Powered Tools

The Education Services team is also evolving how it creates and delivers training content.

Traditional software training programs often rely heavily on written documentation. While comprehensive, these materials can be time-consuming for busy operational teams to work through.

To improve the learning experience, the team is transforming existing training materials, such as written documentation, presentations, and recorded trainings into dynamic video-based learning modules using AI-powered tools. This approach significantly accelerates the development of training content, giving subject matter experts a more accessible way to review training materials.

Many professionals prefer to learn using video-based training. Short, focused modules allow users to quickly revisit topics and understand exactly how workflows are performed within the system. This initiative turns hundreds of training modules into interactive learning experiences that make it easier for HealthRules Payer users to build and maintain system expertise.

Empowering Health Plan Teams for Long-Term Success

Successful system implementations depend as much on people as they do on technology.

HealthRules Payer provides health plans with powerful automation capabilities, operational flexibility, and the ability to manage complex benefit structures with precision. However, realizing full value requires that users understand how to configure, manage, and optimize their organization’s use of the solution.

Education Services helps health plans build that expertise from the earliest stages of implementation and continue developing it over time.

When organizations invest in training early, they accelerate implementation timelines, improve operational outcomes, and empower their teams to take full advantage of the capabilities within HealthRules Payer.

Discover additional ways that HealthEdge Global Professional Services can help your health plan get more value from your investment in HealthRules Payer with custom code services. Read the data sheet.

Part 2 of a 2-part series, where HealthEdge® Vice President of Product Development Bobby Sherwood discusses how a new operating model can transform care operations for health plans.

In the first installment, Sherwood defined what an ecosystem operating model is, and how it can enable payers to improve care delivery, streamline administrative processes, and improve member outcomes.

Read part one here: Preparing for the Future of Care Management with an Integrated Operating Model.

Continue reading to learn more about measuring success with AI-powered tools, steps to achieving operational transformation, and seamless data sharing.

Investing in Member Engagement and Access

Health plans need to reach and engage members to drive outcomes. Where is HealthEdge investing to make that happen?

One thing that is absolutely critical to driving outcomes is activating your member population. If health plans can’t move the needle on how members are progressing through their health journey, the plan is going to struggle to demonstrate meaningful impact.

We’re significantly expanding our HealthEdge Wellframe™ solution, moving it beyond purely an app experience to include web, text-based, and email-based engagement, which is what members have come to expect in today’s digital age. We’re opening more front doors, more channels for members to come in and engage with their care team and become active participants in their own care plan.

Beyond that, we’re also focused on helping our customers and their clinical teams do more with their existing resources by targeting specific, high-impact use cases. In care management, we’ve taken a build-and-partner approach—developing features that drive operational efficiency while also forming strategic partnerships that extend capabilities. For care management, we view artificial intelligence (AI) as an augmenter and enhancer, empowering teams to work smarter rather than replacing their expertise. But there’s still opportunity for AI to take on tasks and work fairly autonomously while still keeping a clinician in the loop.

Annual health assessment completion is a prime example of how AI-powered solutions can securely and transparently enhance member outreach at scale. Today, advanced AI tools can conduct telephonic conversations with members, always making clear that the interaction is assisted by AI, and ensuring privacy and data security remain paramount. This approach not only increases efficiency and reach but also builds member trust by keeping interactions transparent while enabling health plans to engage large populations effectively—far beyond what traditional person-based methods allow.

Ultimately, the effectiveness of these investments hinges on our ability to help health plans engage more members in meaningful ways. Expanding our reach is crucial; without it, achieving measurable improvements in outcomes remains out of reach for both our clients and those they serve.

Measuring Success: Just Start

Health plans are also under intense pressure to prove ROI. How should leaders think about measuring success when adopting Care Solutions within an ecosystem operating model?

My answer is simple: just get started.

Evaluate a use case you’re already familiar with. Work with a partner that brings strong technology, services, and a skilled, comprehensive team to the table. Let them demonstrate how they can deliver better results than your current approach.

Define what “better” looks like for your organization—it could mean higher engagement on your portal, more completed assessments, closing more care gaps, or any of the performance metrics health plans typically track, such as NCQA, HEDIS, or STAR ratings. Focus on one area and work with a partner to deliver measurable value. Once you see proven results, you can expand the program with confidence.

Success measurements should be tailored to what matters most to each health plan’s business strategy. The key advantage of our integrated ecosystem operating model is our ability to contractually guarantee outcomes, because we have control over the entire technology stack and operational process—not just isolated components.

The Future Operating Model

If we’re having this conversation three years from now, what will the most successful health plans be doing differently as a result of embracing an integrated ecosystem operating model?

We’re looking at a complete shift in how health plans operate. The traditional model relies on additional staff or incremental efficiencies—which doesn’t allow for true transformation. In the future, our integrated ecosystem operating model reduces the administrative operating burden, adds expertise and allows health plan staff to focus on high-value work.

Over time, payers continue to see improved outcomes and cost reductions and gain the ability to focus on bigger strategic goals. Partnering with organizations that track and deliver measurable outcome metrics frees up their time, budget, and headspace. They are able to really focus on how they want to compete, how they want to differentiate, and how they want to win. They can leverage resources and talent on their unique strategic priorities, whether that’s specific member populations, clinical specialties, or market differentiation.

The most successful health plans will have a fundamentally different operating model. These health plans will deploy resources toward activities that move the needle on their strategic objectives, rather than getting bogged down by operational tasks that can be performed more efficiently through specialized partners and advanced technology.

And I want to emphasize—this isn’t about eliminating jobs, downsizing or taking away opportunities. This is about removing the work people find most tedious and giving nurses and care managers their passion back for why they got into this profession in the first place.

Steps to Operational Transformation

For plans just starting this journey, what’s the best first step toward moving from point solutions to a true integrated ecosystem operating model?

Our Advisory Services team works with health plans to deliver a total cost of ownership assessment and to determine their cost drivers and areas for improvement. This exercise helps health plans consider a specific line of business use case as a starting point to demonstrate clear ROI and realize immediate administrative efficiencies.

Post-discharge follow-up, member enrollment, or assessment completion are great examples because the intervention-to-outcome relationship is well established and measurable.

Once you prove the value of the model with one line of business, expansion becomes much easier to justify and implement.

Leverage Seamless Data Sharing & Transparency with GuidingCare

What else do you want health plan leaders to know about this transformation?

First, interoperability and seamless data sharing set us apart in the industry. Our entire GuidingCare platform suite shares a unified data model and API framework enabling direct, real-time integration with health plan systems. Unlike solutions that rely on piecemeal acquisitions or fragile partnerships, HealthEdge delivers true interoperability out of the box. We can work directly in systems as the direct source of truth, with direct documentation and all the automations and intelligence built in. That greatly simplifies how these interactions and services are delivered.

Second, embracing an ecosystem operating model is not just an operational shift—it’s a true business model innovation. Health plans that adopt this approach are positioning themselves for sustained success in an increasingly competitive market and evolving contracting frameworks. By moving beyond traditional software acquisitions, health plans equip themselves with a differentiated, future-oriented model that accelerates sustainable growth and delivers long-term value.

Future-Proofing Health Plan Operations with AI-Powered Solutions

The market is changing rapidly. Existing cost and regulatory pressures aren’t going away, and new challenges emerge every day. The question for health plan leaders is whether they want to keep doing things the way they’ve always been done, or whether they’re ready to move beyond the familiar and proactively shape the future of their organization’s success.

Learn more about how your health plan can leverage AI-powered tools to enable strategic, scalable, and intelligent automation. Read the data sheet, Transforming Utilization Management with an AI-Powered Decision Intelligence Ecosystem.

About Bobby Sherwood

Bobby Sherwood is VP of Product Development at HealthEdge, where he leads strategic direction for the company’s cloud-based care management solutions and Business Process as a Service offerings. With deep expertise in healthcare technology and payer operations, Bobby works with health plans to transform care delivery models and drive measurable outcomes.

 

Part 1 of a 2-part series, where HealthEdge® Vice President of Product Development Bobby Sherwood discusses how a new operating model can transform care operations for health plans.

In this installment, we cover:

• What is an ecosystem operating model?
• Addressing workforce shortages with AI
• Redesigning care delivery to improve outcomes

In part 2, Sherwood shares more about measuring success with AI-powered tools, steps to achieving operational transformation, and seamless data sharing.

Nobody goes to nursing school to push paper.

What if care managers could reclaim time currently lost to authorization reviews and compliance chases? Imagine redirecting those hours from administration and back to what really matters: engaging members, improving outcomes, and transforming care through meaningful relationships.

That’s the fundamental shift happening in healthcare now. Health plans are under unprecedented pressure from rising medical costs, regulatory demands, and workforce shortages. And the traditional approach—like layering on additional software and hiring more staff—isn’t sustainable. Something has to change.

At HealthEdge®, we’re delivering a different approach: an ecosystem operating model. We combine next-generation, AI-enabled technology with services designed to lower total costs—and we build contractual accountability into the model.

We sat down with Bobby Sherwood, Vice President of Product Development, to explore how this operating model goes beyond traditional software, and why measurable outcomes are raising the bar.

Defining the New Standard: What is an Ecosystem Operating Model?

How do you define an ecosystem operating model? And how is it different from traditional business process outsourcing?

Traditional business process outsourcing is essentially labor cost arbitrage—taking existing processes and doing them cheaper, often through offshoring or team scaling. You’re doing the same work, just with different people.

Our ecosystem operating model is fundamentally different. We’re reimagining the entire process through technology to deliver transformational outcomes, not just cost savings. It’s about operational transformation, not just labor efficiency.

Here’s what makes our approach unique: we combine HealthEdge’s integrated solution suite with clinical expertise and AI-driven automation. But most importantly, we take accountability for actual care outcomes. We’re not just providing technology. We’re building toward taking responsibility for moving the needle on medical cost trends, member satisfaction, and clinical quality measures.

That accountability changes everything. We succeed only if you succeed. The partnership dynamic is completely different from a traditional vendor relationship.

Supporting a Strategic Shift for Health Plans

HealthEdge is already delivering and optimizing an ecosystem operating model for health plan customers. What does that shift really mean for health plans, and why is now the right moment?

This evolution gives health plans unprecedented flexibility and choice within a full-stack, integrated ecosystem. Health plans can leverage delivery options to focus on which business metrics matter most for their specific strategies and do more with existing capabilities and resources.

Now is the right moment because the traditional vendor model has created fundamentally misaligned incentives. Historically, health plans license software through contracts that aren’t directly tied to member outcomes or total cost performance. While these tools can enable improvement, the commercial model itself isn’t structured around shared accountability for results.

Our ecosystem operating model reshapes legacy systems, and HealthEdge moves beyond vendor status to become a performance-aligned partner. This means our success is directly tied to delivering the specific clinical and financial outcomes that matter to each health plan. We’re accountable for results, not just software uptime. And frankly, the market is ready for this. Health plans are facing a perfect storm of pressures that’s making them more open to different arrangements.

Addressing Workforce Shortages with AI

Speaking of those pressures—rising medical costs, regulatory demands, workforce shortages—which one is forcing the biggest operational change right now?

If I had to pick one, it’s workforce shortages. Health plans can’t hire clinical staff fast enough to keep pace with member growth, stringent regulatory requirements, and the increasing complexity of care management.

This shortage is driving urgent interest in our approach. When you can’t solve the operational bottleneck by adding more people, you have to fundamentally reimagine how work gets done.

This is where AI technology within HealthEdge GuidingCare® becomes exceptionally powerful. Our system empowers health plans to address staffing shortages by automating routine tasks and enhancing clinical efficiency. Features like Automated Clinical Summaries and Intelligent Document Processing reduce administrative burdens, while Intelligent Care Guidance and Ambient Intelligence streamline decision-making and ensure documentation completeness. This allows health plans to redeploy clinical resources to high-impact activities like complex case management and member relationship building, improving care outcomes and operational efficiency.

Think about authorizations. Most nurses did not go into the profession to review paperwork. But authorizations take up so much time and budget because of the compliance burden. If we can demonstrate at scale that we’ll handle all of it, keep health plans compliant, guarantee the savings, and deliver the outcomes health plans need, nurses will gladly hand-off that work. Then health plans can shift those nurses to activities that truly impact the cost curve.

Redesigning Delivery for Measurable Impact

Historically, care management technology has focused on tools and workflows. How is HealthEdge’s Care Solutions approach different in terms of the outcomes it’s designed to deliver?

Traditional care management technology asks, “How can we make existing processes more efficient?” We ask, “What outcomes does the health plan need to achieve, and how do we redesign the entire care delivery model to get there?”

In traditional software models, vendors provide powerful tools that enable improvement, but responsibility for realizing the full value often rests primarily with the health plan. While renewals can reflect satisfaction over time, the commercial structure itself is typically based on access to technology rather than shared accountability for measurable outcomes.

When financial accountability is tied directly to outcomes, the dynamic changes entirely. You’re not just another vendor in their stack of dozens or hundreds of vendors. You become a true strategic partner, fully invested in your clients’ success, with mutually aligned incentives and shared accountability for real, measurable outcomes. This fundamentally transforms the engagement from a transactional relationship into a collaborative alliance built on trust, transparency, and joint achievement.

Our integrated platform doesn’t just digitize existing workflows. It reimagines them entirely. Instead of managing care through disconnected systems and manual processes, our platform enables seamless orchestration of member engagement, clinical interventions, and administrative processes. The result is measurable improvements in clinical quality, member experience, and cost management that we contractually guarantee.

Ready to learn more about reaching and engaging members, measuring the ROI of an ecosystem operating model, and how to get started?

Read part 2 of the blog here: Adopting an Ecosystem Operating Model and Measuring ROI.

About Bobby Sherwood

Bobby Sherwood is VP of Product Development at HealthEdge, where he leads strategic direction for the company’s cloud-based care management solutions and Business Process as a Service offerings. With deep expertise in healthcare technology and payer operations, Bobby works with health plans to transform care delivery models and drive measurable outcomes.

 

Health plans are heading into 2026 under a level of pressure that feels fundamentally different from just a few years ago.

Findings from the HealthEdge® 2026 Healthcare Payer Survey Report, “The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance,” paint a picture of an industry navigating intensifying regulatory demands, rising cost pressure, accelerating AI adoption, and growing gaps between strategy and execution.

Taken together, these signals point to something bigger than incremental change. The healthcare operating model itself is shifting, and many organizations are being forced to reconsider how their business is structured and how work actually gets done.

From Optimization to Reinvention

For years, many health plans focused on improving workflows, optimizing processes, tightening controls, and driving incremental efficiency.

That approach is starting to give way to something more fundamental.

The survey findings suggest that organizations are not just adjusting priorities. They are rethinking how their operations are designed altogether. Investments are being redirected, infrastructure is being modernized, and long-standing assumptions about how the business runs are being challenged in response to rising costs, regulatory complexity, and increasing expectations from both members and providers.

Cost management continues to dominate executive attention, while compliance requirements grow more complex and more visible. At the same time, initiatives tied to AI, automation, and digital engagement are gaining traction across the enterprise.

Strategies for Reducing Costs

 

Source: 2026 Healthcare Payer Survey Report, The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance

Individually, these shifts are significant. Together, they point to a clear reality: incremental improvement is no longer enough. Health plans are being pushed toward structural reinvention.

Transformation Is the Strategy. Execution Is the Challenge.

While the ambition to transform is nearly universal, the ability to execute remains uneven.

HealthEdge’s survey highlights that:

• 94% of payers are live with or adopting AI, yet only 31% report fully defined governance models
• Executive leaders express more confidence in transformation progress than operational and regulatory teams
• A perception gap persists — only 51% of members view their plan as a “partner in care,” compared to 76% of payers who believe they are perceived that way

What emerges is a pattern: transformation is moving quickly, but alignment across the organization is not keeping pace.

The Pace of AI Adoption at Health Plans

 

AI Governance Maturity at Health Plans

 

That misalignment shows up in different ways, including unclear governance, uneven confidence, and gaps between intent and experience. The question is no longer whether modernization is happening. It’s whether organizations are equipped to make it work at scale.

The Technology Partnership Pivot

As complexity increases, health plans are also rethinking how capabilities are built and sustained.

The survey points to a growing recognition that core functions, such as claims processing, payment integrity, and care management, cannot operate effectively in isolation. When these workflows are connected, organizations gain better visibility, reduce duplication, and create more consistent outcomes.

At the same time, automation is becoming more deeply embedded in day-to-day operations. When applied directly within claims and engagement processes, it has a measurable impact on administrative efficiency and administrative loss ratio (ALR) performance. Governance is evolving as well, with leading organizations, like HealthEdge, designing compliance and auditability into their systems from the start rather than addressing them after the fact.

All of this reflects a broader shift. The traditional model, which was built on fragmented systems and siloed processes, is giving way to something more coordinated, where data, workflows, and decisions are more tightly connected.

Why the Health Plan Pressure Is Increasing

Several forces are converging to accelerate this shift.

• Regulatory Velocity – Compliance requirements continue to expand, with greater scrutiny on auditability, prior authorization, payment accuracy, and AI governance. New mandates are not only increasing oversight but also requiring faster, more transparent data exchange—forcing organizations to rethink both systems and processes.
• Cost and ALR Pressure – Administrative cost containment remains a constant focus. As margins tighten, leaders are looking more closely at automation, payment integrity, and operational efficiency—not as incremental improvements, but as essential levers for sustaining performance.
• Member Expectations – At the same time, expectations from members continue to evolve. The gap between perception and experience is notable: while most plans believe they are seen as partners in care, only about half of members agree. Closing that gap requires health plans to deliver experiences that feel connected, transparent, and trustworthy.

These pressures are not temporary disruptions. They reflect a longer-term shift in what it takes to operate effectively as a health plan.

How HealthEdge Is Helping Plans Navigate Industry Shifts

As organizations move beyond optimization, a consistent theme emerges: transformation only works when it is integrated, governed, and measurable.

HealthEdge is helping health plans make that transition by embedding AI and automation directly into core workflows, from claims adjudication to payment integrity and member engagement. At the same time, configurable governance controls and audit-ready frameworks support greater transparency and compliance.

By connecting pricing, editing, and review workflows, plans can reduce administrative burden while improving financial performance. And with unified data models and enterprise-wide visibility, leaders are better equipped to align strategy with execution.

The goal is not to layer new tools onto legacy systems, but to support a more durable shift in how operations are structured and managed.

A Trusted Partner to Embrace Ongoing Change

The findings from HealthEdge’s 2026 Healthcare Payer Survey point to a clear inflection point. Incremental improvement is no longer sufficient. Health plans are entering a period where structural change is required across technology, operations, and governance.

Those that succeed will be the ones that bring these elements together into a more connected, adaptable operating model.

Want to learn more about the ways health plan leaders are already integrating AI-powered tools into their workflows? Read our recent article, “Unlocking the Future of Healthcare Technology: Interoperability, Transparency, and AI”.

Large language models (LLMs) are inherently probabilistic, meaning the same input can produce different outputs. That variability makes traditional unit tests, which verify exact results, ineffective for AI systems. In healthcare, where quality and accuracy are nonnegotiable, this creates a unique challenge: how do you ensure AI performs reliably at scale? At HealthEdge, we address this through a multi-layered evaluation strategy that combines human evaluations, LLM-as-a-Judge, CI/CD automation, and online, real-time monitoring to meet healthcare’s rigorous quality standards.

Why do we need multiple evaluation types?

Each serves a distinct purpose in the AI development lifecycle:

• Human evaluations establish ground truth. Only domain experts can judge whether an AI summary captures clinically relevant details or if generated test cases are actually executable. Humans define what “good” looks like.
• LLM-as-a-Judge scales human judgment. We can’t have subject matter experts (SMEs) review every output during rapid development. A judge-LLM applies human-defined criteria consistently across thousands of examples, enabling fast iteration.
• CI/CD regression evaluations prevent quality backslides. When prompts or models change, automated tests catch regressions before they reach production, which is essential when multiple teams ship AI features weekly.
• Online (real-time) evaluations catch real-world drift. Production traffic contains edge cases that no test dataset anticipates. Continuous monitoring detects degradation before users complain.

We’ll illustrate each type of evaluation using our QA Test Case Generation Agent, which reads Jira tickets and generates test cases with titles, preconditions, steps, and expected results.

Human Evaluations

Human evaluations are the gold standard. For healthcare AI, human oversight is non-negotiable. AWS Bedrock supports this through human-based evaluation jobs: collect inference examples, upload to S3, create evaluation jobs with custom metrics, and review results through Bedrock’s console.

SMEs are best suited for measuring the performance of highly complex operations. For instance, the QA Test Generation Agent takes in a nontrivial input, a Jira ticket, and outputs an entire spreadsheet of test cases with multiple test steps. It takes a multitude of steps to translate from input to output, all of which simulate the role of a QA engineer.

LLM-as-a-Judge

LLM-as-a-Judge uses a second LLM to evaluate primary agent outputs, scaling human-like judgment across large datasets without requiring SME time for every evaluation run.

Each evaluation metric is defined by a prompt that instructs the judge LLM what to assess and how to score. For example, a “Relevance” evaluator prompt asks the LLM to compare the generated output to the source input and rate how relevant the response is. These evaluation prompts can be customized for domain-specific criteria, allowing teams to encode their quality standards into reusable, automated checks.

When initially building LLM-as-a-Judge evaluators, it’s helpful to compare their scores against human evaluations on the same dataset. This calibration ensures the LLM evaluators resemble SME judgment as closely as possible. If the judge LLM scores differ significantly from human reviewers, the evaluation prompt needs refinement until alignment improves. Bedrock offers built-in evaluators for correctness, relevance, and hallucination, as well as custom prompts.

For the QA Test Generation Agent, the same criteria evaluated by SMEs can be provided as prompts for the LLM judges, providing a secondary aggregate of metrics. Acting as a baseline, they can indicate any dips in performance of the agent.

CI/CD Regression Evaluations

CI/CD evaluations automate quality gates. When developers merge changes to prompts, models, or agent architecture, automated evaluations catch regressions before they move into production.

AWS AgentCore integrates with GitHub Actions to configure datasets, define LLM-as-a-judge evaluators, and specify task functions. The pipeline triggers on the merge, blocking deployment if thresholds aren’t met.

For example, with the HealthEdge QA agent, we block if test comprehensiveness, as evaluated by an LLM as a comparison with ground truth data, drops below 80% or CSV output format adherence falls below 95%.

Online (Real-Time) Evaluations

Online evaluations monitor production traffic, sampling live requests to detect drift that static datasets miss. These evaluations use the same LLM-as-a-Judge evaluators defined during development, applying them continuously to production data rather than pre-constructed test sets. AgentCore supports configurable sampling (1-5% of traffic), running judge prompts on sampled requests and surfacing score trends through observability dashboards. If quality degrades from unexpected inputs, online evaluations catch it before users report issues.

The Evaluation Lifecycle

These four evaluation types form a continuous loop: human evaluations establish ground truth; LLM-as-a-Judge enables rapid iteration; CI/CD gates releases; online monitoring feeds edge cases back into development.

AI evaluation requires fundamentally different approaches than traditional testing. By combining human evaluations, LLM-as-a-Judge, CI/CD automation, and real-time monitoring, HealthEdge ensures AI features meet healthcare’s quality standards.

To follow HealthEdge’s AI strategy in greater detail, visit the Resources section of our website, www.healthedge.com.

For the second consecutive year, 52% of health plan executives named “managing rising costs” as the top challenge, according to the 2026 HealthEdge® Annual Payer Report.

In the same survey, 85% of executives reported that regulatory compliance requirements directly cut into their margins. Health plans using HealthEdge HealthRules® Payer enter this environment with the advantage of a next-generation core administrative processing system (CAPS) designed specifically for these challenges. The next opportunity is to expand that advantage across your organization’s workflows by adopting an integrated operating model.

From Next-Generation Software to a Modern Operating Model

HealthRules Payer delivers capabilities that legacy systems cannot match, including rapid configuration, high auto-adjudication rates, and the flexibility to quickly adapt to regulatory changes.

Across the industry, health plans that have modernized their CAPS still operate within traditional organizational structures and practices. Internal teams, external vendors, and contracts are organized by function, each with its own disparate accountability and performance tracking. That model leaves significant operational value on the table because of persistent inefficiencies like:

• Low visibility & fragmented accountability. Separate teams and vendors manage claims, enrollment, billing, and member services, each under distinct contracts and using unique performance tracking. This reduced transparency prevents cross-functional collaboration and efficiency.
• Downstream lag on configuration changes. The platform adjusts rapidly, but the operation around it may take weeks to catch up. Retraining staff, updating enrollment procedures, and revising compliance documentation all follow separate timelines.
• High administrative costs. Without operational transparency and integration, staffing overhead and managing multiple vendors can dilute the efficiency gains HealthRules Payer delivers.
• Compliance execution that remains reactive. Each regulatory change triggers a cross-team operational scramble managed as a special project rather than an adaptable, repeatable workflow.

These are operating model challenges and, left unaddressed, they compound. Technical debt grows, capital stays locked in maintenance, and the ability to expand into new markets or new lines of business narrows. Overcoming these challenges requires integrated platforms that can handle rapid modernization to deliver outcomes.

An Integrated Operating Model with Guaranteed Financial Outcomes

Moving to a modernized operating model is a structural change. Software ownership gives way to outcome accountability. Siloed systems and multiple vendor relationships give way to an end-to-end operating ecosystem managed by a single partner.

The HealthEdge integrated operating model consolidates technology, operational processes, and a dedicated global service delivery team under a single governance structure and set of service-level agreements (SLAs). The partner who builds the platform is also the one who operates it and is accountable for the results, with contractually guaranteed cost reductions tied to defined performance measures.

This is a different approach than patching point solutions onto an existing environment or layering new tools on top of an outdated operating structure. Those practices may address some symptoms, but they can add costs and do not change the underlying model. An integrated ecosystem replaces the model itself.

Across current deployments, health plans operating within this model have achieved:

• 30–40% reduction in administrative cost per member per month (PMPM), sustained year-over-year.
• Return on investment (ROI) within 12–15 months, compared to 24–36 months under multi-vendor approaches.
• Budget variance below 1%, against an industry benchmark of 10–15%.

With HealthEdge, these are contractual commitments—not projections.

Turning a Technology Advantage into an Operational One

For health plans already operating on HealthRules Payer, the integrated operating model means having a dedicated team with deep expertise in the platform, acting as an extension of your organization to ensure that investment works harder across every function.

One Accountable Partner, End to End

HealthEdge owns the platform, the global operations delivery team, and the outcomes. Vendor sprawl and split accountability are replaced by a single point of responsibility for performance, backed by shared risk. Ongoing platform upgrades and regulatory updates are included at no additional cost.

Configuration Changes That Execute at Platform Speed

When a benefit rule, pricing change, or regulatory update is configured in HealthRules Payer, the downstream operational response is managed by one team at a rapid pace. New lines of business that take months under traditional models can launch in days.

Administrative Costs Decrease and Stay Down

Standardized work processes, automated task processing, and economies of scale across a global delivery team of more than 7,000 drive 30–40% reductions in health plan administrative costs, sustained year over year. Savings are tied to process enhancement rather than headcount reduction. You pay for measurable results, not employee hours or resource inputs.

Compliance Built into Daily Operations

Centers for Medicare and Medicaid Services (CMS) mandates like the Transparency in Coverage final rules, state requirements, and audit readiness tools are embedded into standard workflows within HealthRules Payer. Plus, regulatory changes are operationalized as they arrive.

Real-Time Visibility Across the Full Operation

A centralized data hub in the platform surfaces performance data through unified executive dashboards. Backlogs, SLA risks, and compliance exposure become visible before they become problems.

Leadership Reclaims Time for Strategy

When a single partner manages daily execution and owns the outcomes, health plan leadership moves capacity toward growth and member experience.

The HealthEdge advisory team works alongside health plan leadership from day one to ensure operational continuity.

The New Operating Model in Practice

One regional health plan moved to an integrated ecosystem model, unifying core administration, claims, enrollment, billing, correspondence, and member services under a single HealthEdge operating structure in fewer than 12 months.

The payer’s administrative spend dropped from $11.50 to $6.90 per member per month (PMPM), a reduction of approximately 40%. Claims accuracy reached best-in-class levels, and the plan reported EBITDA uplift across every function in the model.

Operational improvements like these are still the exception among health plans, though they are available to any organization. Adopting a fully integrated technology-and-operations model can help put your health plan at the forefront of the adoption curve, giving your organization a competitive advantage.

Learn more about the power of an integrated operating model in action. Download our case study to see how one health plan successfully migrated its entire ecosystem under pressure and achieved a 99.8% auto-adjudication rate.

A Practical Way to Get Started Now

HealthEdge offers a cost-driver assessment that builds a baseline of current administrative spend, identifying where costs originate and where an integrated model would generate the greatest return. Whether a health plan moves forward with HealthEdge or not, the assessment delivers an independent, practical view of the current operation.

Contact us to learn more.