How integrated HealthEdge® technology helps improve member outcomes, reduces spend, and delivers on the promise of coordinated care.

Ask any care manager why they chose their profession, and the answer is almost always the same: a deep desire to help people. What most don’t anticipate are the hours spent manually entering data, reconciling duplicate records, or chasing down missing information instead of with their patients.

Too often, care managers are pulled away from member support tasks to battle escalating administrative demands. The result? Avoidable complications, frustrated staff, disengaged members, and rising costs.

An Expensive Ripple Effect

When a member in need doesn’t know who to call or where to go, they often turn to the most accessible (and expensive) point of entry: the emergency room. For payers, this creates a significant financial burden, as emergency visits and subsequent hospitalizations drive up costs. It can also be difficult to coordinate with a member’s PCP or primary care team after discharge, potentially exacerbating the issue and increasing the likelihood of swift readmissions and compounding expenses.

These avoidable costs can strain health plan resources and impact overall financial performance. But health plans can help break this reactive, costly cycle through proactive measures such as member education, helping coordinate timely follow-up appointments, medication reconciliation, and guidance toward cost-effective care options. By addressing these gaps, payers can reduce unnecessary utilization and improve both financial outcomes and member satisfaction. 

However, care managers are often forced to hunt for crucial information across disparate systems. This lack of integration isn’t just inconvenient—it creates significant risks. Every additional action increases the chance that data goes unseen, instructions get missed, or members receive redundant, and frustrating, outreach. When members receive the same messages and are asked to repeat their medical history multiple times due to system limitations, trust begins to erode. Their engagement drops. And without engagement, care management becomes far less effective.

This fragmentation is equally taxing for clinicians and care teams. When systems slow them down—or worse, prevent them from helping members—providers feel it deeply. And burnout can become contagious.

“At the heart of it, nurses want to provide the best care for their members,” says Jennie Giuliany, RN, and Senior Director of Clinical Care Solutions at HealthEdge. “If they get frustrated because they can’t, it can negatively impact both job satisfaction and member experience.”

The Power of Consolidation and Intelligent Technology

The path to better care begins with data consolidation. When all relevant data lives within a single platform, care managers can move beyond reactive troubleshooting to intentional coordination. This reduces the number of touchpoints required to resolve an issue and eliminates redundant questioning. More importantly, it allows members to feel seen, which is perhaps the most underrated form of care.

Technology plays a key role in helping coordinate care, but not as a replacement for clinical instinct. Instead, modern platforms augment human expertise. For example, the HealthEdge AI Summarizer tool can easily and quickly condense complex medical histories into a digestible view. Evidence-based, best-action recommendations offered directly within the HealthEdge GuidingCare® platform can then lead care managers to the right interventions faster. Business rules engines can further automate tasks that once consumed hours of manual effort. Collectively, these tools reduce the time spent on documentation and free up time for clinicians to connect with members.

GuidingCare’s Optical Character Recognition (OCR) technology can also automatically read and route clinical documents in seconds. Prior authorization requests, faxed records, and other attachments move straight into the right workflow—no manual sorting required. Paired with configurable rules, this helps plans make decisions faster, reduce denials fatigue, and align with evolving compliance needs.

Digital engagement also broadens reach. While some members live on their phones and prefer asynchronous messaging, others crave voice-to-voice reassurance, especially when navigating a new diagnosis. Still others may have limited internet access—a common issue, even in dense cities where infrastructure can block connectivity. In this case, tools like Mobile Clinician, an extension designed for in-home visits without reliable connectivity, allows nurses to complete assessments and auto-generate care plans offline, syncing later. Nothing gets lost and no visit is wasted.

True transformation happens when this ecosystem of tools exists within a unified suite. An end-to-end platform delivers richer analytics, a complete view of member history, and a single source of truth for both care managers and providers. With HealthEdge integrated solutions—GuidingCare, Wellframe™, Mobile Clinician, and robust analytics—health plans gain the full clinical and financial benefit of coordinated care. When HealthEdge systems connect, data becomes actionable instead of simply stored, empowering teams to intervene earlier, engage members more effectively, and reduce unnecessary utilization.

Proactive Care Over Reactive Cost

Connecting critical data unlocks the potential for early intervention. Risk analytics and integrated datasets can identify members who are newly diagnosed, trending toward higher utilization, or likely to slip through the cracks without support. With these insights, care managers can offer resources before member conditions deteriorate—without the mounting frustration of navigating multiple systems. Digital tools can also help care managers identify opportunities for education, medication management, and follow-up appointments with far greater speed and accuracy, thanks to automated workflows and intelligent guidance built into the platform.

As regulations continue to change, plans need to respond quickly. With rapid rules deployment in GuidingCare, teams can update business logic in hours instead of months. Paired with standardized workflows, this helps reduce denials backlogs, support NCQA alignment, and protect reimbursement.

One-stop-shop care management platforms also help coordinate the broader care team, from providers and behavioral health specialists to family caregivers. Centralizing this communication reduces duplicative outreach, minimizes confusion, and reinforces a shared plan of action. With fewer handoffs to manage manually, care managers can better educate, coordinate, and encourage preventative visits that cost far less than acute hospitalizations. Over time, this approach shifts spending from acute care to preventative care—a marker of success.

The Future: Technology That Honors the Human Side of Care

Looking ahead, artificial intelligence (AI) will continue to shape the healthcare landscape. But health plans must maintain caution and ethical standards. Healthcare organizations have historically been hesitant to implement new technologies, which is understandably grounded in the need to protect patient safety and privacy. Today’s AI tools are not designed to replace clinicians but supplement their judgment, point to evidence-based criteria, and simplify regulatory documentation.

“We’re using AI in a way that helps guide clinicians, not replace them,” Giuliany notes. “By reducing the time required to find and cite relevant information, AI can ease administrative weight and improve compliance-driven workflows—especially as regulatory expectations continue to rise.”

At the end of the day, lowering costs through effective care management doesn’t hinge on working harder. It’s rooted in working smarter with technology that supports the human side of healthcare rather than overwhelming it.

Delivering better care shouldn’t mean adding complexity. With the full suite of HealthEdge integrated solutions—spanning care coordination, digital engagement, offline flexibility, and intelligent guidance, plans can reduce avoidable costs while elevating the member experience. Because when clinicians are free to focus on care, better outcomes follow. And better outcomes are always worth the investment.

Ready to make care management work smarter, not harder? Explore how the HealthEdge connected ecosystem can help your teams reduce spend, streamline workflows, and keep the focus where it belongs: better care for every member.

Download the case study: How a Regional Health Plan Unified Care Management with HealthEdge.

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At HealthEdge®, we understand that efficient provider data management is fundamental to delivering quality healthcare. Yet, the reality for many health plans is that maintaining accurate provider directories involves labor-intensive, manual processes that consume valuable staff time.

Provider data management teams process thousands of roster updates annually, including new provider enrollments, terminations, address changes, and specialty updates. Each change traditionally requires manual data entry, taking up to 5-10 minutes per update. When multiplied across thousands of changes per organization each year, the administrative burden becomes substantial.

The challenge extends beyond time investment. Manual data entry introduces room for error, creates processing backlogs, and diverts skilled staff from higher-value work like provider relationship management and network adequacy analysis. Health plans need a smarter approach to handle the growing volume of provider documentation while maintaining data accuracy.

Introducing the PIF Intake Agent

HealthEdge is working to address these challenges head-on with our new Provider Information Form (PIF) Intake Agent. This AI-powered solution automates the extraction of provider information from submitted documents and streamlines the creation of workflow tickets in our Provider Data Management solution.

The PIF Intake Agent is currently deployed within HealthEdge’s internal operations, and external availability is planned for later this year. The current internal deployment allows us to validate performance, accuracy, and integration workflows before broader rollout.

Rather than replacing human judgement, the PIF Intake Agent handles the repetitive extraction and data structuring tasks, presenting organized information to provider data staff for review and approval. It currently processes PIFs for new provider enrollments and termination requests, which can contain information for single or multiple practitioners, as well as multiple service locations within a single submission.

The solution intelligently determines the appropriate workflow type based on document content. When processing a submitted form, the AI agent automatically identifies whether the request involves a new provider enrollment or a termination, then executes the corresponding workflow.

How the Solution Works

The PIF Intake Agent operates through a streamlined pipeline that transforms unstructured documents into actionable workflow tickets.

The underlying architecture leverages a Model Context Protocol server that exposes workflow tools to a Large Language Model-powered agent. The agent operates according to carefully crafted prompts that define data extraction rules, required field mappings, and validation logic.

When a provider document enters the system, our OCR pipeline extracts text and structured data from the submitted form.

The AI then analyses this content to identify key information, such as Practitioner names, National Provider Identifiers (NPIs), Addresses, Specialty codes, Effective dates.

The system intelligently distinguishes between individual practitioners and organizations, recognizing when multiple providers or locations appear within a single document.

For specialty information, the system integrates with a specialty translation service that converts human-readable specialty names, like “Family Medicine,” into standardized healthcare taxonomy codes required by the Provider Data Management database.

For complex documents containing multiple practitioners, the agent creates separate workflow tickets for each distinct entity. This ensures that your provider data management staff can process each provider independently while maintaining a clear audit trail that links all tickets back to the source document.

The extracted data flows into our Provider Data Management solution as structured tickets, complete with all required fields populated. Staff members can then review the pre-filled information, make any necessary corrections, and approve the changes — a process that takes seconds rather than minutes.

Integration with Existing Workflows

A key design principle for the PIF Intake Agent was seamless integration with existing provider data management operations. The solution embeds directly within established workflows, requiring no fundamental changes to how teams operate.

The agent interfaces with our Provider Data Management APIs to translate extracted specialty and taxonomy codes into the system’s required format. When a document contains a specialty description like “Family Medicine,” the system automatically maps this to the appropriate code values needed for the Provider Data Management database. This translation happens automatically, eliminating a common source of data entry errors.

Document traceability remains central to the design. Each workflow ticket maintains links to its source document, enabling staff to reference the original submission whenever questions arise. This supports compliance requirements and provides the documentation necessary for audit purposes.

Delivering Operational Impact

The PIF Intake Agent significantly reduces the time required to process provider roster updates. By automating the extraction and structuring of provider data, health plans can handle larger volumes of updates without proportionally increasing staff workload.

Data quality improvements accompany the efficiency gains. Automated extraction eliminates transcription errors common in manual data entry, while standardized field mapping ensures consistency across all processed documents. The human review step maintains quality control while benefiting from AI-prepared data.

Health plans can redirect time savings toward activities that require human expertise: resolving complex provider inquiries, managing network relationships, and addressing data discrepancies that require investigation. The agent handles the routine extraction work, freeing skilled staff for higher-value contributions.

Looking Ahead

The PIF Intake Agent represents one component of HealthEdge’s broader AI platform strategy. The underlying architecture, which combines document intelligence with workflow automation, creates a foundation for expanding AI capabilities across additional use cases.

As we continue enhancing the solution and preparing for its release to clients later this year, we’re focused on expanding support for additional document types, including organization updates and W9 tax forms, thus improving extraction accuracy for edge cases, and adding intelligent routing capabilities that direct complex requests to appropriate specialists. These enhancements will further reduce processing times while maintaining the data quality standards that health plans require.

For health plans seeking to modernize their provider data management operations, the PIF Intake Agent offers a practical path forward — delivering immediate efficiency improvements while establishing infrastructure for continued AI-powered innovation.

Contact HealthEdge to learn how our AI solutions can streamline your provider data management operations.

When state regulations change, health plans must be ready to respond—particularly when those changes impact core Medicaid services. That was the case in 2025 when the State of Texas mandated updates to the Medical Necessity and Level of Care (MNLOC) assessment process. MNLOC is a required evaluation used to determine eligibility for long-term services and supports (LTSS), such as those covered under the STAR+PLUS waiver program.

Health plans operating Medicaid lines of business in Texas needed to implement these updates quickly to remain compliant. Several organizations relying on HealthEdge GuidingCare® engaged the HealthEdge® Global Professional Services team to help deliver the required enhancements.

What is MNLOC and Why Does It Matter for Health Plans?

MNLOC is a comprehensive, state-mandated assessment that evaluates a person’s medical condition, cognitive ability, behavioral health, and functional status to determine whether they require nursing facility-level care. The results of this assessment are submitted to the Texas Medicaid & Healthcare Partnership (TMHP) for adjudication, with outcomes that drive downstream service planning and authorization.

For health plans serving Medicaid populations, MNLOC assessments are a cornerstone of LTSS program compliance. The process is meant to ensure:

• Adherence to state and federal guidelines
• Accurate benefit utilization
• Alignment with value-based care models
• Prevention of unnecessary institutionalization
• Delivery of services based on individual member needs

Revamping the MNLOC Workflow

The MNLOC assessment is only one part of a broader workflow that spans technology systems and departments. First, care managers conduct the assessment within the GuidingCare platform. That data is then transmitted to the TMHP portal, where it is processed and returned with Resource Utilization Group (RUG) values. These values guide service authorizations generated within GuidingCare, enabling health plans operating in Texas to deliver timely and appropriate care.

The Global Professional Services team enhanced the payer’s MNLOC workflow by building a direct API integration from GuidingCare to the TMHP portal, eliminating the need for health plans to serve as intermediaries. This simplification improved response times and enabled faster service authorizations while maintaining regulatory compliance.

Automation That Supports Care Managers

To reduce manual effort and ensure consistency, the Global Professional Services team built automation directly into the MNLOC assessment workflow. For example, when a care manager enters start and end dates for a service, the GuidingCare platform automatically calculates the appropriate duration based on allowable hours per week and the availability of family caregivers. The system pulls data from related assessments, applies state-specific logic, and pre-populates relevant fields, helping deliver accurate, actionable information without complex manual calculations.

This level of configurability makes it easier for care teams to comply with requirements without pulling focus from delivering person-centered care.

Built to Scale, Delivered with Speed

One of the biggest differentiators of the HealthEdge Global Professional Services team is its deep expertise in both the GuidingCare platform and state-specific Medicaid workflows. When the MNLOC update was announced, Global Professional Services delivered the required solution on a compressed timeline—less than 2 weeks from start to finish. This rapid execution was made possible by GuidingCare’s modern architecture and Global Professional Services’ close collaboration with HealthEdge product experts.

Because Global Professional Services works closely with the GuidingCare product team, health plans benefit from faster, higher-quality services and solutions, something third-party consulting firms often struggle to match. This alignment also reduces long-term maintenance burdens and ensures that future regulatory changes can be addressed efficiently across markets.

Reducing Costs and Complexity

As part of the implementation, Global Professional Services migrated data storage from a commercial third-party solution to a custom .NET framework built by the HealthEdge team. The new framework eliminated recurring third-party licensing fees and helped health plan customers improve alignment with the GuidingCare platform to enhance care coordination.

Strategic Compliance, Operational Confidence

To keep pace with evolving Medicaid programs, health plans need agile solutions that can adapt to regulations without disrupting care coordination and delivery. The MNLOC workflow project highlights how the HealthEdge Global Professional Services team supports operational agility through a unique combination of technical expertise, regulatory insights, and seamless collaboration with product teams.

With HealthEdge Global Professional Services, health plans don’t just meet compliance deadlines. They gain a trusted partner that helps them streamline operations, reduce administrative burden, and deliver high-quality, value-based care.

Learn more about our Global Professional Services offerings.

Implementing new care management technology is about more than just meeting a go-live date. For Medicaid and Long-Term Services and Supports (LTSS) plans navigating evolving state mandates, success hinges on achieving regulatory compliance agility—the ability to adapt swiftly and confidently to continuous change.

This theme was the focus of a recent webinar hosted by the Association for Community Affiliated Plans (ACAP), hosted by implementation and regulatory leaders from HealthEdge® and Nascentia Health. They shared how Nascentia completed a nine-month, compliance-focused implementation of HealthEdge GuidingCare® that strengthened care management operations, reduced risk, and empowered its care management teams.

In the webinar, speakers also highlighted five key lessons the Nascentia team learned from their experience, and how HealthEdge implementation best practices helped embed regulatory compliance agility into every stage of the process.

Five Key Implementation Lessons from Nascentia Health

1. Start with compliance as a priority on day one

Nascentia made regulatory compliance the foundation of its implementation. The plan’s compliance team was involved from the first assessment through post-go-live evaluation, ensuring every workflow, form, and report aligned with state and federal requirements.

“Start with compliance as a priority on day one,” said Brian Davey, Vice President of Health Plan Operations at Nascentia. “One of the main reasons we achieved a nine-month timeline was because there was not much rework. Compliance was involved every step of the way.”

Implementation Best Practices

• Integrated compliance and regulatory leaders into each phase, from discovery through testing.
• Mapped all regulatory touchpoints early and defined measurable compliance outcomes.
• Used the proprietary HealthEdge Transform Framework to connect compliance requirements directly to solution delivery.

The most successful health plans treat compliance as an enterprise-wide foundation rather than a separate workstream. Compliance serves as a governing focus that spans the entire program and supports the organization’s broader goals.

2. Build shared accountability between your health plan and technology partner

Nascentia and HealthEdge adopted a “one-team” model, fostering transparency and mutual accountability through daily communication, shared milestones, and joint decision-making—key elements for a rapid and compliant rollout.

Implementation Best Practices:

• Established shared project dashboards and escalation paths to track progress.
• Embedded compliance checkpoints into project governance for joint approval at each stage.
• Maintained open communication through regular stand-ups and weekly syncs.
• Treated implementation as a collaborative transformation, not a handoff.

This model helped Nascentia stay on schedule and ensure compliance remained central. “It was a true partnership from the beginning,” said Davey. “We trusted each other and problem-solved in real time.”

3. Strengthen internal capacity early

From the outset, Nascentia prioritized sustainability by employing a “train-the-trainer” approach. This strategy empowered internal champions to manage configuration, updates, and training well beyond go-live. This focus included the following results:

• 20 internal champions trained
• 90% of configuration changes now handled in-house
• Approximately 7 full-time equivalents (FTEs) saved through automation and efficiency gains

Implementation Best Practices:

• Provided hands-on training and documentation during implementation to build lasting in-house expertise.
• GuidingCare’s configurable technology enabled quick workflow and form updates without HealthEdge support, supporting internal capability rather than vendor dependence.
• Paired plan leaders with HealthEdge subject matter experts to ensure smooth knowledge transfer.

4. Select a partner with proven regulatory experience

Nascentia needed a technology partner that understood New York’s Medicaid and LTSS environment, including Department of Health (DOH) requirements for Uniform Assessment System (UAS) assessments, Person-Centered Service Plan (PCSP) workflows, and SmartComm letters. HealthEdge brought deep experience in state-specific mandates and a proven record of compliance-ready implementations.

Implementation Best Practices:

• Used pre-built, audit-tested assets aligned to the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and state requirements.
• Leveraged HealthEdge’s Regulatory Change Management Model, which tracks mandates and crosswalks them to product capabilities.
• Offered transparency through the HealthEdge Trust Portal, with SOC2, HITRUST, and HIPAA documentation accessible to the health plan and auditors.
• HealthEdge maintains a regulatory pipeline incorporating learnings from emerging changes and customer advisory boards.

Choosing a partner with deep regulatory expertise allowed Nascentia to reduce implementation risk and accelerate go-live—achieving a timeline “about 40% faster than the industry average,” according to Davey.

5. Track early wins and share them across the organization

Nascentia measured and shared progress from day one, building internal momentum. Early wins—like improved audit readiness and faster updates—reinforced the platform’s value across teams. Outcomes achieved include:

• 15% increase in nurse capacity
• Reduced burnout and manual workload
• Real-time adaptability to DOH guidance changes
• Seamless integration across lines of business

Implementation Best Practices:

• Defined early success metrics tied to compliance, efficiency, and user adoption.
• Shared dashboards and reports with leadership to maintain visibility and confidence.
• Continued optimization after go-live to build on early gains.

Nascentia’s success demonstrates how measurement and transparency foster engagement, ensuring that compliance improvement becomes an integral part of daily operations rather than just a project milestone.

A Model for Compliant Care Management Implementations

The partnership between HealthEdge and Nascentia showcases the transformative potential of embedding compliance into every layer of technology and teamwork. Starting with compliance, shared accountability, and measuring shared outcomes provide a clear blueprint for health plans who want to modernize their care management systems.

The lessons proven through this partnership validate HealthEdge’s best practices for implementation success, including:

• Embed compliance into design and testing.
• Operate under a one-team model.
• Empower health plan staff with configurable tools.
• Leverage regulatory expertise and prebuilt assets for rapid, compliant and effective implementation.
• Measure, communicate, and sustain improvement for material business improvement.

Compliance agility extends far beyond audit readiness. It serves as a protective foundation for the organization, strengthens teams, and enables better care delivery.

Want to watch the full discussion between leaders from Nascentia and HealthEdge? Watch the webinar on-demand: “Care Management Software Implementation Best Practices.”

The healthcare payer landscape is undergoing a seismic transformation, as revealed by the 2026 HealthEdge® Annual Payer Report. HealthEdge surveyed more than 550 health plan executives, including 348 leaders focused on Medicare, Medicaid, and Dual-Eligible populations. This year’s findings highlight business growth and competitive pressure – as well as costs—as the top challenges for government plans.

Challenge 1: Growth, Competition, and the Cost Crunch

For the second consecutive year, “managing rising costs” remains the leading concern across all payers surveyed (52%). However, “business growth and competitive pressure” have surged, up 16 percentage points year-over-year, to tie as the top challenge.

Among government plans, “business growth and competitive pressure” is the number one challenge. This is a 47% increase from the previous survey, signaling a maturing market where differentiation, retention, and strategic partnerships are critical for long-term viability. According to respondents, workflow automation, artificial intelligence (AI), and advanced analytics are favored strategies for achieving a competitive advantage.

Challenge 2: Regulatory Pressures and Technology Modernization

The regulatory landscape has intensified, especially following the enactment of the One Big Beautiful Bill Act (OBBBA). Nearly 90% of payers focusing on government plans report “moderate to significant” impacts on their costs and overall margins due to changing regulatory requirements.

When it comes to technology, the biggest compliance challenge is no longer fee schedules but a lack of internal IT staff and resources. Only about half of health plan leaders report being fully operationalized or making progress to meet key regulatory guidelines—underscoring the urgent need for vendor partners that can deliver foundational offerings that can automate new rule integration and improve regulatory compliance.

Challenge 3: Value-Based Care and Provider Engagement

Siloed data and legacy systems continue to hinder the scalability of value-based care (VBC) models. While 93% of payers who focus on Medicare, Medicaid, and Dual-Eligible populations have VBC arrangements in place, and 72% expect these contracts to increase, integration challenges persist.

Thirty percent of payers cited “integrating provider data across systems” as their biggest challenge in provider data management. VBC growth now depends on breaking down data silos and modernizing digital infrastructure. When it comes to improving provider relations, government plans place the highest priority on increased provider collaboration and VBC contracting (26%).

Challenge 4: Member Satisfaction—Vulnerability and Opportunity

Member satisfaction is both a growing vulnerability and a strategic opportunity. Seventy percent of government health plans cite high out-of-pocket costs and premiums as the top challenge to member satisfaction, followed by claims denials (55%), and network access issues (53%). To address these pain points, 42% of health plans are prioritizing faster, more accurate claims payments to boost engagement.

Yet, a perception gap persists: only 53–60% of government plan members view their health plan as a partner as reported in the 2025 HealthEdge® Consumer Survey, compared to 77–81% of payers who believe they are perceived that way. Improving member experience is the first step for closing the trust gap and driving long-term engagement.

The Path Forward: Modernization, Personalization, and Partnership

To stay competitive, health plans must modernize their technology ecosystems and leverage business models such as BPaaS (business process as a service) to help streamline workflows, scale operations, and maintain compliance readiness.

In addition, prioritizing member experience through personalized outreach, digital tools like mobile apps and chatbots, and clear communication is vital to long-term improvements in clinical outcomes and member retention.  Ultimately, success hinges on transforming operations from transactional to relational, delivering value at every touchpoint and securing sustainable growth.

To explore the full findings and actionable insights specifically for leaders of government plans from the 2026 HealthEdge Annual Payer Report, watch our webinar with ACAP on-demand now: The Shifting Priorities of Health Plan Leaders: Key Insights from the 2026 HealthEdge Payer Survey.