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Transform Health Plan Operations with AI-Powered Core Administration 

Posted on by HealthEdge

Artificial intelligence (AI) has become the catalyst for transformation across various industries, and healthcare is no exception. For health plans, the integration of AI is no longer just a future aspiration; it is a present-day necessity. From enhancing operational efficiency to improving member outcomes, AI-powered core administration solutions are reshaping how health plans operate on virtually every level.  

HealthEdge® endeavors to be at the forefront of this transformation by thoughtfully integrating AI tools across our suite of digital solutions. Within HealthRules® Payer, our core administrative processing system (CAPS), we’re leveraging AI to help payers streamline workflows, reduce administrative costs, and modernize member experiences.  

Explore a few of the ways AI-powered core administration solutions are transforming healthcare operations and how HealthEdge is developing digital solutions to put health plans at the forefront.  

The Growing Role of AI in Healthcare  

Healthcare organizations across the industry are adopting AI at an unheralded pace, largely driven by the promise of improved operational efficiency, reduced costs, and better care outcomes. According to one McKinsey analysis, for every $10 billion of payer revenue, AI solutions could save $150 million to $300 million in administrative costs.
And more than 80% of health plans are already integrating AI into their workflows. 

AI-driven solutions can enable health plans to achieve critical business goals such as:  

  • Facilitating Intelligent Claims Operations. Using AI, payers can automate more of the claims process to enhance accuracy, improve fraud detection, and reduce payment friction. 
  • Delivering Proactive and Integrated Care. AI tools can surface predictive insights that enable providers to deliver personalized care that meets members’ holistic needs. 
  • Elevating Member and Provider Experiences. AI-enhanced solutions can make it easier for payers to personalize interactions at scale with intelligent tools. 
  • Enhancing Cost Efficiency. Automating data validation, streamlining workflows and reducing the need for manual intervention can help payers lower administrative costs without sacrificing scale. 
  • Ensuring Regulatory Compliance. AI-powered tools can help track and organize essential information necessary for reporting and other regulatory guidelines. 

AI-Driven Innovation in the HealthRules Payer CAPS Solution 

HealthRules Payer exemplifies how AI can revolutionize healthcare operations. Designed with automation, agility, and intelligence in mind, HealthRules Payer enables health plans to adapt to the rapidly evolving market. 

HealthRules Payer is driving transformation across health plan operations with targeted AI-powered tools:  

Automating Claims Administration  

With intelligent claims processing, steps such as claims adjudication, contract management, and financial validation are automated to achieve consistently high accuracy. For example, HealthRules Payer helped one health plan achieve a 90% first-pass auto-adjudication rates, significantly reducing manual intervention and associated costs.  

Real-Time Decision-Making  

AI-enabled tools within the proprietary HealthRules Language helps simplify benefits configuration and enhance accuracy through real-time recommendations. This feature allows health plans to streamline decision-making processes while maintaining flexibility in adapting to market demands. 

Unstructured Data Automation  

Extracting and structuring data from documents, faxes, and forms is traditionally a time-consuming process. By automating this task, HealthRules Payer removes administrative bottlenecks and accelerates workflows.  

Claims Summarization and Support  

The Claims Summarizer, an AI-powered feature, offers concise summaries of pending or denied claims. This helps claims processors quickly identify issues and make informed decisions, further enhancing efficiency.  

Elevating Member Interactions  

Through AI-powered chatbots, HealthRules Payer supports members and customer service teams with instant, accurate answers to questions about claims, benefits, and membership. This strengthens member satisfaction and engagement.  

HealthRules Payer also integrates seamlessly with other solutions in the HealthEdge digital ecosystem, creating a unified platform that leverages automation and real-time data to deliver unmatched value.  

How HealthEdge AI Tools Can Transform Core Healthcare Functions 

The power of AI-driven solutions extends well beyond claims processing to other critical areas of healthcare operations. HealthEdge integrates AI capabilities across its suite of solutions to fully realize its potential. Key applications include: 

Payment Integrity 

HealthEdge Source™ enables payers to drive payment accuracy and integrity through customizable edits and automated contract setup to help reduce payment friction, maintain compliance, and improve payer and provider experiences.  

Provider Network Management 

AI simplifies the management of provider data with tools that intelligently match and merge records, reducing the need for manual reconciliation. The HealthEdge® Provider Data Management solution acts as a single source of truth for accurate and consistent provider information.  

Care Management 

HealthEdge GuidingCare® uses AI to automate tasks for care teams and surface actionable insights to facilitate proactive outreach. Tailored care recommendations help prioritize next steps and improve care outcomes.  

Member Engagement 

HealthEdge Wellframe™ combines real-time insights with intelligent automation to create personalized, seamless experiences for members. AI supports care managers by suggesting message responses and flagging high-risk members based on their interactions.  

By addressing these operational pain points, HealthEdge is helping to set a strong foundation for the future of healthcare operations. 

Responsible AI Development at HealthEdge 

HealthEdge understands that deploying AI in healthcare must include a commitment to transparency and ethical practices. That’s why HealthEdge has built a robust framework focused on responsible AI that prioritizes security, fairness, and compliance.  

HealthEdge’s approach to responsible AI development includes: 

  • Transparency and Risk Mitigation: Proactively addressing concerns related to data privacy, governance, and algorithmic biases. 
  • Alignment with Industry Frameworks: Following guidelines such as the Artificial Intelligence Risk Management Framework (AI RMF 1.0) and the Coalition for Health AI (CHAI). 
  • Collaborative Innovation: Partnering with health plans, end users, and industry stakeholders to align AI capabilities with real-world needs. 

By adhering to these principles, HealthEdge is helping ensure that our solutions are not only innovative but also trusted by our customers. 

The Future of Healthcare Operations  

With its cutting-edge AI capabilities, HealthRules Payer is empowering health plans to redefine how they operate, serve members, and deliver care. Whether it’s managing claims, engaging members, or facilitating care coordination, the opportunities AI presents are immense. 

Are you looking for a new CAPS solution, but aren’t sure which vendor is the right partner for your organization? Download your complimentary copy of the Gartner® Market Guide for U.S. Healthcare Payers’ Core Administrative Processing Solutions. 

 

 

 

Strengthen HEDIS Performance with Digital Member Engagement

Posted on by HealthEdge

Quality performance expectations have reached a turning point in 2025. This year’s Healthcare Effectiveness Data and Information Set (HEDIS) measures, developed and maintained by the National Committee for Quality Assurance (NCQA), place greater emphasis on preventive care, chronic disease management, and social determinants of health (SDOH). These updates require health plans to adapt quickly to remain competitive. 

To meet these elevated expectations and strengthen HEDIS performance, health plans must engage members as active partners in whole-person care. This means going beyond clinical interventions to promote preventive screenings and address social barriers. The HealthEdge Wellframe™ member engagement platform supports this shift by enabling health plans to transition from reactive workflows to proactive, measurable quality improvement strategies using digital tools. 

Adapting to A Shifting Quality Measurement Landscape 

NCQA continues to evolve HEDIS to better reflect whole-person care, with three core areas defining 2025’s elevated standards: 

  • Engagement-Driven Prevention. New metrics measure how effectively health plans engage members to follow through on preventive care, including screenings, immunizations, and early interventions. Documenting that services occurred is no longer sufficient—health plans must demonstrate improved health outcomes and health risk reduction. This shift rewards organizations that foster relationships and use tools such as digital engagement to promote preventive clinical best practices. 
  • Whole-Person Quality Metrics. HEDIS measures now incorporate SDOH, such as housing, food access, and transportation. Health plans are expected to address medical, behavioral, and social factors of members’ lives. Through partnerships with community-based organizations (CBOs) and the use of closed-loop referrals, health plans can reduce barriers to quality care. 
  • Real-Time Performance Standards. Expectations from NCQA and the Centers for Medicare & Medicaid Services (CMS) increasingly require standardized, real-time clinical quality data analysis. Health plans must refine their existing clinical quality and risk adjustment initiatives to show a commitment to improving outcomes, reducing disparities, and advancing value-based care across Medicare, Medicaid, and Marketplace programs. Similar to Star Ratings, HEDIS measures play a central role in health plans’ clinical quality strategy. To stay aligned, health plans must shift from batch reporting to continuous monitoring that identifies care gaps and tracks interventions as they occur. 

In this context, persistent operational and data analytic challenges remain for many health plans. Fragmented data sources limit visibility into members’ needs and delay outreach from care teams, making it difficult to close gaps in a timely manner. Many care teams rely on outdated manual processes that use multiple technology platforms, creating additional barriers and requiring an increasing amount of administrative resources. Traditional approaches cannot guarantee that care gaps are addressed before they negatively impact clinical quality measures. 

At the same time, the financial risks are growing. Low HEDIS performance can lead to significant penalties, while top-tier scores boost Star Ratings and member acquisition. As more value-based care contracts link payment to quality, the stakes for health plans are higher than ever. 

Transform Strategy & Strengthen HEDIS Performance with Wellframe

Wellframe helps health plans meet evolving requirements by embedding digital member engagement into clinical quality operations. This integration accelerates care delivery, enhances member support, and enables a more responsive, whole-person approach.  

Real-Time Intelligence Drives Early Action

Wellframe captures data as members interact with the platform, surfacing care gaps and risk signals earlier. Digital surveys, screening tools, and health assessments offer insights into both clinical and non-clinical needs. 

Predictive capabilities enable Wellframe to identify care gaps and surface them so care teams can conduct individual or group outreach.  For example, pregnant members may receive timely reminders to schedule prenatal visits, while members managing diabetes receive personalized nudges for HbA1c testing and eye exams. These early interventions help maximize impact within quality measurement windows. 

This intelligence enables care teams to take proactive steps to encourage screenings, address chronic conditions, and respond to emerging concerns before they escalate.  

Member-Centered Engagement Builds Stronger Connections 

Wellframe supports member engagement across multiple touchpoints, including two-way messaging with care teams, personalized push notifications, and tailored educational content delivered through the mobile devices members use every day. 

This model improves adherence to screenings, diagnostic testing, and treatment plans that influence HEDIS measures. By meeting members where they are and offering convenient, personalized experiences, Wellframe turns passive engagement into active participation. 

Personalized Programs Support Whole-Person Care 

Managing chronic conditions, maternal health, or preventive goals requires more than one-size-fits-all communication. Wellframe delivers customized digital care programs tailored to each member’s circumstances, including known social risk factors. 

Members experiencing food insecurity can be referred to community-based support. Individuals facing transportation challenges may be eligible for transportation assistance to attend in-person appointments. These personalized interventions drive better health outcomes and higher quality scores. 

Demonstrable Value Delivered by Wellframe

Wellframe delivers measurable results across quality metrics, operations, and member experience, such as: 

  • Enhanced Care Team Efficiency. Care teams using Wellframe can scale their outreach while continuing to deliver personalized support. According to HealthEdge data, health plans have doubled their active caseload capacity and increased member interactions up to sixfold by leveraging intelligent workflows that automate routine tasks, streamline documentation, and prioritize high-risk members. This enables care teams to facilitate care gap closure and enhance coordination across health plan clinical quality and compliance teams. 
  • Higher Member Satisfaction. Members consistently rate their experience with Wellframe highly (an average of 4.7 out of 5 stars in the App Store). For many members, digital communication lowers barriers to care and fosters stronger relationships with their health plan. Satisfied members are more likely to complete screenings, adhere to care plans, and engage long-term to strengthen overall performance. 

Building a Future-Focused Quality Strategy

HEDIS measures reflect how effectively health plans deliver quality, equitable, and consistent care. As expectations rise, digital transformation is essential. 

Wellframe enables timely outreach, tailored education, proactive reminders, and transparency in the care journey. Integrated with care management systems, these tools help health plans close whole-person care gaps more efficiently, engage members at risk, and align with top HEDIS priorities. 

As NCQA and CMS continue to evolve value-based care and clinical quality standards, Wellframe evolves alongside them. With HealthEdge, health plans gain a strategic partner committed to continually improving member outcomes and advancing equity, member engagement and operational performance. 

Strengthen HEDIS performance at your health plan with digital member engagement. Learn how Wellframe helps health plans deliver proactive outreach, close care gaps faster, and elevate the member experience. 

 

Enhance Automation and Cost Savings with EDGEcelerate Optimization Services

Posted on by HealthEdge

Your health plan is constantly growing and expanding—and your digital ecosystem should be able to keep pace and scale with your organization. Whether your health plan is adding new lines of business or adapting to new government regulations, it’s critical to regularly assess and optimize technology solutions. Periodic review of your digital ecosystem can help:

  • Automate and streamline workflows
  • Enhance cost savings
  • Adopt modern product capabilities
  • Ensure regulatory compliance

Digital optimization can have significant financial and operational benefits for health plans. According to the 2024 CAQH Index, the medical industry can reduce its administrative costs by $18B by moving from manual to electronic transactions. For example, it costs a payer $3.41 to manually process a prior authorization. When the authorization is processed electronically, it costs $0.05—a savings of 98% per transaction. Similarly, when a health plan pends a claim and works it manually, it can add 1-2 weeks to the claim’s processing time.

How Can Optimization Services Support Health Plan Strategy?

Many health plans are interested in strategic optimization but aren’t sure where to begin. The best place to start is with an optimization assessment. Delivered by HealthEdge® Global Professional Services (GPS) subject matter experts, an optimization assessment is a strategic engagement to evaluate your current HealthEdge system set up and workflows. Our team also provides a detailed, prioritized report of recommendations and next-step guidance. The goal of the assessment is to identify improvement opportunities, reduce operational costs, enhance the end-user experience, and ensure you realize the full value of your HealthEdge solutions.

Our Global Professional Services team can also support targeted optimization projects. For example, our GPS team partnered with a customer who was facing a common challenge: matching claims with authorizations. Our subject matter experts assessed their system and identified multiple opportunities to improve their claim-authorization matching. As a result, this customer achieved a 56% reduction in their pend rate for authorization-related claims—that’s a 56% reduction in claims requiring manual work!

Another key area for optimization and cost savings is automation. The 2024 CAQH report highlighted prior authorizations as a prime candidate for automation, noting that on average, providers and staff spend 24 minutes per prior authorization request when using phone, fax, or email. This past year, HealthEdge Global Professional Services released the Prior Authorization Catalog, an advanced rule processing engine that automates prior authorization decisions. This scalable solution is designed to handle high volumes of data, enabling payers to support complex decision automation while simplifying workflows for health plan administrators.

EDGEcelerate Optimization Services from HealthEdge

Our Global Professional Services Team is committed to helping our customers harness the power of optimization to ensure their technology evolves alongside their business. To achieve this, we offer EDGEcelerate, a flexible subscription-based GPS offering designed to help health plans unlock the full potential of their HealthEdge solutions. With EDGEcelerate, you gain a dedicated allocation of Global Professional Services support hours each year—allowing you to optimize, adapt, and innovate faster without the administrative burden of managing multiple contracts.

Why EDGEcelerate?

  • Optimization-Focused: Shift from reactive, one-off projects to a proactive, planful strategy that maximizes your technology investment.
  • Flexibility: Choose the level of support your organization needs and use your allocated hours across a wide range of initiatives—no need for separate contracts for every project.
  • Predictability: Simplified, subscription-based contracting gives you faster access to expert resources and greater control over your budget.
  • Dedicated Expertise: Partner with a consistent team of HealthEdge product and industry experts who know your systems, your business model, and your goals.

To learn more, read the full EDGEcelerate data sheet or contact your Customer Success Executive.

How an Integrated Digital Ecosystem Enables Success for Health Plans

Posted on by HealthEdge

Health plan executives face increasing demand to deliver frictionless experiences, from streamlined operations to a modern member experience, to stay competitive in a rapidly evolving market. At the core of health plan operations is the core administrative processing system (CAPS). To truly elevate performance, health plans need a next-generation CAPS solution that can support an integrated digital ecosystem.

While these integrations might feel like a technical headache, their importance cannot be overstated. Real-time, seamless connections between systems ensure businesses can operate efficiently and remain agile. When designed strategically, a health plan’s integrated ecosystem can provide significant operational, financial, and experiential benefits. Here’s how integrations within a health plan ecosystem align with business goals and drive success.

Why Integration Matters in a Health Plan’s Ecosystem

A best-in-class health plan ecosystem consists of critical solutions such as billing, claims processing, member services, provider networks, and more. If not properly integrated, each component operates in a silo, causing inefficiencies, data inaccuracies, and cumbersome workflows.

Integrating these systems offers competitive advantages, such as:

  • Real-Time Data Sharing: Critical data, such as claims information or member profiles, flows seamlessly across digital solutions, reducing errors and bottlenecks.
  • Improved Member and Provider Experience: Integration streamlines processes to provide faster responses, improved transparency, and personalized interactions.
  • Operational Efficiency: Automated workflows replace manual processes, reducing administrative burdens and overall operational costs.
  • Agility for Growth: Integrated ecosystems adapt easily to industry changes, such as evolving compliance regulations, value-based care models, or new product launches.
  • Better Decision-Making: Comprehensive, integrated data equips health plan leaders with actionable insights to make informed decisions.

A health plan ecosystem truly thrives when its core system and supporting components communicate seamlessly, creating a foundation for innovation and success.

The Role of Integration in Core Administrative Systems

At the center of health plans lies modern core platforms like HealthRules® Payer, which are purposefully built to integrate seamlessly with other systems. Here’s why integration with HealthRules Payer is paramount to achieving holistic ecosystem functionality:

Seamless Real-Time Connectivity

The HealthRules Payer Solution Suite leverages an enterprise-class integration layer that enables real-time and batch access to data. Stakeholders—including members, providers, brokers, and pharmacies—can interact with reliable, up-to-the-minute information for better service and collaboration.

Simplified Data Exchange with Industry Standards

Gone are the days of dealing with complicated APIs or legacy database systems. Standardized APIs and interoperability tools ensure HealthRules Payer integrates smoothly with partner systems and external exchanges while meeting compliance requirements like HIPAA.

Affordable Maintenance

One challenge of integration is the long-term cost, particularly when updates roll out. HealthEdge combats this with its Upgrade Assurance Program, ensuring that custom integrations remain functional after each update or release at no extra charge. This minimizes downtime and preserves investment longevity.

Streamlined Ecosystem with Proven Touchpoints

HealthEdge’s HealthRules Payer already supports nearly 100 integration touchpoints, from financial systems to provider data management platforms. By offering pre-built connections to common third-party solutions, health plans enjoy faster implementation, reduced costs, and a more robust ecosystem.

Integration in Action Across Key Functions

To better understand how system integration supports health plan goals, here are examples of its impact across critical business areas:

1. Customer Service

Integrated customer service platforms ensure that a member’s health history, claims data, and benefits information are easily accessible, empowering representatives to resolve issues quickly and efficiently. For example, virtual assistants powered by AI can retrieve and provide this information in real time, cutting call times and improving first-call resolution rates.

2. Human Resources (HR)

From talent acquisition to employee benefits management, integration allows HR systems to connect seamlessly with payroll platforms and benefit providers. This creates a more streamlined process for managing internal administrative needs, keeping employees satisfied and productive.

3. Claims Processing and Adjudication

Legacy claims systems often create bottlenecks, but integration reduces these inefficiencies. Claims data integrates directly with pricing, provider networks, and compliance systems, enabling faster adjudication for cleaner claims and higher auto-adjudication rates. HealthEdge clients, for instance, achieve first-pass auto-adjudication rates of over 90%.

4. Provider Collaboration and Network Management

Real-time provider API support ensures accurate payment processing and data-driven contract negotiations. More seamless communication between health plans and providers streamlines payments, strengthens relationships, and fosters trust[CY1] [AM2] . HealthEdge® Provider Data Management enables health plans to automate data ingestion and matching across multiple sources, streamlining validation processes and improving compliance.

5. Data Analysis and Reporting

Integrated systems empower health plans to unify siloed data for comprehensive reporting. Leaders gain actionable insights into member behavior, claim trends, cost efficiencies, and more through analytics dashboards supported by platforms like HealthRules Answers. This data fosters informed decision-making and enables better forecasting.

Building Future-Forward Solutions with HealthEdge

HealthEdge takes an innovative, modern approach to integration with its HealthRules Connector. Built on advanced architecture, this solution goes beyond enabling compatibility. It establishes a foundation for continual improvement by enabling health plans to adopt emerging technologies and industry best practices, whether these involve AI tools for claims adjudication or consumer engagement systems.

By reducing the costs and complexity of ecosystem management, HealthEdge not only helps health plans succeed today but also future-proofs their technology stack.

Harness the Power of Integration to Meet Your Goals  

Integrating systems within your health plan ecosystem is no longer optional—it’s essential to stay competitive, reduce costs, and improve member satisfaction. The ability to exchange comprehensive, real-time data while maintaining flexibility significantly enhances operational efficiency and enables your team to achieve and exceed critical business goals.

When selecting a partner for system integration, choose one that prioritizes both innovation and reliability. HealthEdge’s HealthRules Payer ecosystem offers a modern, fully integrated platform designed to surpass industry challenges while making your health plan more agile, efficient, and impactful.

Let’s build a smarter, more connected healthcare ecosystem together. To learn more about how the integrated HealthRules Payer solution can provide better data access across your organization and help your teams prepare for the future of healthcare. Read the case study, How One Regional Health Plan Created a Member-Centric Digital Ecosystem.

 

Improve Care Coordination and Delivery with AI & HealthEdge GuidingCare®

Posted on by HealthEdge

Healthcare is undergoing a transformation, and artificial intelligence (AI) is a major part of this evolution. From improving diagnostic accuracy to transforming care coordination workflows, AI offers extraordinary opportunities for enhancing efficiency, quality, and patient outcomes. For health plans, this means adopting innovative solutions that not only keep pace with industry demands but also set new standards for care delivery and operational excellence.

HealthEdge GuidingCare® is at the forefront of this revolution, leveraging advanced AI tools to redefine how health plans coordinate and deliver care for its members. Below, we’ll discuss why AI is essential for care coordination, the unique benefits provided by GuidingCare, and the AI-powered features that make it stand out.

Why Leverage AI to Improve Care Coordination?

Care coordination is more complex than ever. The shifting healthcare landscape, characterized by expanded data streams, growing patient populations, and value-based care models, demands intelligent tools capable of managing these challenges. AI-infused technology is not just a nice-to-have tool for health plans; it has become a necessity.

According to the IDC MarketScape: U.S. Care Coordination Technology 2024–2025 Vendor Assessment, health plans looking to improve care coordination should prioritize solutions that deliver:

  • Patient-Centric Care
  • AI & Personalization
  • Clinical Decision Support
  • Interoperability
  • Data Security
  • Cost Efficiency

HealthEdge stands out as a leader in this space, recognized for offering advanced AI-enabled tools that address these critical areas. With GuidingCare, health plans gain a platform optimized for real-time insights, automation, and meaningful care delivery.

What Makes the GuidingCare Care Management System Different?

Unlike many care management systems, GuidingCare enables payers to support end-to-end care coordination workflows through a fully integrated platform. GuidingCare gives providers a 360-degree view of each member, allowing for more accurate risk stratification, making it easier to deliver targeted assessments, interventions, and outreach. The solution also integrates with social services platforms to help uncover members’ social risk factors and make it easier to connect members with essential support services.

The highly configurable GuidingCare system supports a wide variety of health plan workflows, including alerts, care plans, business rules, reporting, and assessments. Plus, providers receive alerts as part of their regular workflows, including overdue activities, changes in member risk scores, new hospitalizations, and other shifts in member activity.

Health plans can configure GuidingCare to work for their unique business needs, benefit plans, and member populations and enable workflow automation. HealthEdge solutions comply with FHIR interoperability requirements and offers APIs for a bi-directional integration approach that efficiently connects GuidingCare with a health plan’s existing technology ecosystem.

With these capabilities in place, GuidingCare empowers health plans with the tools needed to deliver personalized, high-quality care at scale.

How the GuidingCare System Leverages AI

HealthEdge’s AI strategy takes a thoughtful, secure approach that focuses on enabling smarter workflows, actionable insights, and enhanced member experiences. By embedding advanced AI into GuidingCare, health plans can access features that go beyond mere automation to improve care coordination, delivery, cost, and outcomes through predictive insights and automation. GuidingCare users are better able to meet the needs of members and providers using intelligent workflows—improving not only their experiences, but their access to essential care services.

1. Intelligent Care Guidance

AI-powered recommendations provide care teams with tailored next steps that align with clinical guidelines and individual member needs. By prioritizing these actions, health plans can streamline care coordination and improve outcomes.

2. Automated Clinical Summaries

Care managers often spend hours sifting through data. GuidingCare reduces this burden by summarizing care management and utilization information into digestible reports. This feature saves time, reduces cognitive overload, and accelerates clinical decision-making processes.

3. Intelligent Document Processing

Manual document management is resource-intensive and prone to errors. GuidingCare automates document and fax processing, improving workflow efficiency and data accuracy while reducing administrative overhead.

4. AI-Powered User Support

Through in-app chat functionality, GuidingCare delivers quick, conversational responses to questions. Whether it’s accessing training materials or reviewing documentation, this feature helps users increase productivity while gaining confidence in using the system effectively.

These AI-powered enhancements make GuidingCare a truly next-generation care management system, capable of keeping pace with the evolving demands of healthcare.

Responsible AI Practices at HealthEdge

The adoption of AI in healthcare also requires a strong commitment to ethical development and execution. HealthEdge ensures its AI capabilities are aligned with best practices for transparency, fairness, and compliance by integrating frameworks like the National Institute of Standards and Technology (NIST) AI Risk Management Framework.

HealthEdge’s approach includes:

  • Data Privacy and Security: Ensuring compliance with HIPAA and other regulatory requirements.
  • Bias Mitigation: Rigorous testing to avoid algorithmic biases that may compromise equity.
  • Collaboration: Partnering with stakeholders, including providers and members, to ensure AI meets real-world needs.

By prioritizing responsible AI, HealthEdge helps health plans adopt forward-thinking technologies with confidence.

Delivering Value Across the Healthcare Ecosystem

GuidingCare is more than a care coordination solution—it’s a platform that bridges the gap between technology and patient-centered care. Here’s how it benefits key stakeholders:

Health Plans:

  • Automates complex workflows, reducing administrative costs and errors.
  • Personalizes member outreach and engagement, driving better outcomes.
  • Aligns with compliance regulations, minimizing operational risks.

Care Teams:

  • Streamlines decision-making processes with summarized reports and actionable insights.
  • Enhances efficiency through automated tasks and prioritized workflows.
  • Empowers teams to deliver care at the top of their license.

Members:

  • Provides personalized care pathways tailored to their unique health goals and needs.
  • Simplifies access to social services, improving well-being beyond clinical care.
  • Builds trust through transparent, digitally enabled interactions.

A Smarter Way Forward in Care Coordination

The potential of AI in healthcare is undeniable, and tools like GuidingCare have redefined what’s possible for health plans. By providing intelligent, integrated, and actionable solutions, GuidingCare not only addresses today’s challenges but also prepares organizations to thrive in the future of value-based care.

If you’re ready to transform your care coordination workflows and elevate the care experience for your members, explore the capabilities of GuidingCare today. Harness the power of AI to achieve better outcomes, maximize efficiency, and build a healthier tomorrow.

Want to learn more about how HealthEdge solutions are leveraging AI tools to improve care delivery and transform health plan operations? Download our data sheet.

Key Considerations for Evaluating Digital Member Engagement Solutions

Posted on by HealthEdge

The digital transformation of healthcare has fundamentally shifted member expectations. Today’s members expect more than convenience. They want clarity on their care, real-time access to guidance, and tailored support that helps them manage their health and benefits. Health plans must meet these expectations with personalized communication and seamless digital experiences that reflect members’ evolving needs and preferences.

When members have transparency into care plans and next steps, and can interact with care teams continuously, they feel more confident and supported in their health decisions. With one-third of members “very likely” or “likely” to switch insurance plans in the next year, effective digital engagement is a competitive necessity.

For IT executives, evaluating digital member engagement platforms is a strategic decision that influences operational efficiency, member satisfaction, and care outcomes. Poor platform choices can fragment member experiences and overwhelm staff. The right platform, however, can centralize engagement, integrate effectively with a care management solution, streamline workflows, and deliver measurable results across clinical, quality, and financial metrics.

What’s Holding Health Plans Back from Effective Digital Member Engagement?

Despite investments in digital health, many health plans are constrained by legacy systems, siloed technologies, and growing vendor portfolios. The result is often operational inefficiency, inconsistent member experiences, and limited ability to scale or evolve. Some of the pains that health plans experience include:

Disparate Systems and Integration Gaps Create Complexity

Many health plans rely on a collection of point solutions that operate in isolation or require custom integrations. This fragmentation creates inconsistent member experiences, inefficient workflows, and data silos. Care teams may spend more time toggling between systems than engaging with members. Poor interoperability with systems like care management or core administrative processing further impedes whole-person care. Without seamless integration, health plans struggle to identify risks early, coordinate care, or support quality and compliance programs.

Unvalidated Technologies Pose Strategic Risks

The digital health market is saturated with platforms that promise transformative results, but lack demonstrated outcomes. Investing in unvalidated or immature platforms can undermine operational efficiency and erode the member trust that health plans work so hard to build.

Vendor Relationship Complexity Drains Resources

Managing too many vendor relationships creates a substantial administrative burden and complicates support such as IT resources. This complexity often hinders the organization’s agility in responding quickly to evolving member needs and market demands.

4 Attributes of an Effective Digital Member Engagement Solution

To support scalable, sustainable member engagement, health plans should look for platforms that meet four essential criteria:

1. A Comprehensive, Unified Platform.

Consolidated platforms reduce complexity, increase staff efficiency, and ensure a seamless experience for members. Modular designs and high configurability also allow for tailoring solutions to meet specific health plan transformation roadmaps, business models, and member populations.

2. Demonstrated Success with Data-Driven Results.

Health plans should prioritize solutions backed by peer-reviewed studies, customer case studies, and proven performance data. Measurable improvements in cost savings, member satisfaction, and staff productivity distinguish proven platforms from unvalidated tools. It’s also important to look for vendors whose teams bring deep clinical experience and regulatory expertise to help guide implementation, drive adoption and ensure alignment with compliance mandates from the Centers for Medicare and Medicaid Services (CMS), NCQA, and individual states.

3. Scalability and Continuous Innovation.

The healthcare market is dynamic. Platforms must scale with member growth and adapt to regulatory changes like those tied to NCQA Health Equity Accreditation or CMS interoperability mandates. Leading solutions leverage AI and automation to deliver scalable, personalized outreach while supporting plan compliance and quality reporting.

4. Seamless Integration with Care Management.

The most effective digital engagement platforms don’t operate in isolation—they integrate tightly with care management systems and broader infrastructure. By embedding alerts, insights, and chat directly into care manager workflows, integrations reduce workflow disruption and enhance decision-making.

Access to community resources, referral tracking, and SDOH coordination also become frictionless. A well-integrated solution enables more proactive interventions, streamlined collaboration, and more productive care teams without needing to toggle between disconnected tools.

The Proven Value of HealthEdge Wellframe™

The Wellframe digital member engagement platform combines technology, clinical insight, and workflow integration to help health plans achieve measurable performance improvements across engagement, operational efficiency, and member outcomes. Here are five key areas that set Wellframe apart:

A Singular Solution for Member Engagement at Scale

Wellframe empowers health plans to engage and support their full member populations through a single, scalable platform. It offers secure two-way chat, digital health assessments, educational clinical content, and proactive alerts and reminders. These capabilities enable personalized outreach, real-time engagement, and early risk identification aligned with clinical and quality goals.

With omnichannel capabilities and AI-enabled workflows, Wellframe adapts outreach based on each member’s behavior, health risk, and program eligibility. The platform supports preventive care, chronic condition management, and behavioral health while keeping care teams connected with members when and where support is needed most.

Proven Performance Across Clinical and Operational Metrics

At leading health plans, Wellframe has demonstrated:

A Connected HealthEdge Ecosystem Advantage

Wellframe integrates seamlessly with HealthEdge GuidingCare®, a comprehensive care management platform, providing a unified member record that care managers can access and update in real-time. This integration supports real-time care coordination, enhances audit readiness, and allows teams to execute member interventions without jumping between systems.

 Staff Efficiency and Member Satisfaction

Health plans using Wellframe report a 200% increase in care team caseload capacity. The member app maintains a 4.7-star rating in the App Store, a signal of high usability and meaningful member value.

Innovation Driven by Customer Partnership

Wellframe evolves in direct response to health plan feedback. This partnership model ensures continuous alignment with plan goals, upcoming CMS requirements, and new care delivery models. This co-development approach accelerates time to value and keeps customers ahead of the curve.

How to Evaluate Digital Member Engagement Platforms: A Quick Checklist for IT Leaders

To guide your selection of a digital member engagement solution, start by asking:

  • Does the platform unify all engagement functions into a single, scalable solution?
  • Is it tightly integrated with care management to provide a complete view of the member journey?
  • Can it integrate cleanly with our existing technology ecosystem?
  • Are its outcomes backed by credible, data-driven proof points?
  • Can it scale with our growth and adapt to evolving regulatory requirements?
  • Is the vendor a long-term partner committed to continuous innovation and aligned success?

Transform Member Engagement with a Platform That Delivers

Wellframe helps health plans replace fragmented tools with a unified, data-driven approach to member engagement. By combining intelligent workflows, real-time insights, and seamless ecosystem integration, Wellframe enables better care, improved outcomes, and measurable gains across clinical, financial, and member experience metrics.

Learn how Wellframe and the broader HealthEdge ecosystem can help your plan drive transformation, improve member satisfaction, and deliver care with clarity and confidence. Read our case study, “How To Build A Digital Adoption Ecosystem And Deliver Greater Value To Members.”