Elevate Care Management with the Integrated Power of HealthEdge GuidingCare®

Industry pressures like regulatory complexity and the shift toward value-based care demand that health plans take an integrated, strategic approach to care management. Whether payers are evaluating a new care management platform or seeking greater value from an existing solution, precision and a commitment to innovation are essential for success.

HealthEdge GuidingCare® offers an advanced, integrated care management solution that delivers measurable outcomes for care teams, administrators, and members. The GuidingCare platform delivers a robust foundation that enables health plans to maintain core care workflows while improving key areas such as Medical Loss Ratio (MLR) and holistic care delivery. By fully utilizing GuidingCare’s built-in modules, healthcare organizations can eliminate data silos, enhance member engagement, and unlock actionable insights on clinical and financial performance.

Unlock Efficiency by Combining Fragmented Solutions

Fragmented solutions can impede agility and elevate costs. When functions like utilization management and population health analytics exist in isolation, care teams are forced to reconcile disparate data sources, resulting in inefficiencies and delayed interventions. But platforms with built-in integration capabilities can provide a unified view of each member’s journey and enable more personalized outreach.

GuidingCare was built as a modular, fully interoperable digital ecosystem. Whether payers are considering the platform for the first time or expanding their current usage, there are opportunities to enable seamless data flow across care management, digital engagement, analytics, and compliance.

Translating Data into Action: GuidingSigns Analytics

For new adopters, GuidingSigns Analytics provides predictive power that goes beyond conventional reporting to transform retrospective claims data into forward-looking, risk-based intelligence. Existing users can drive even greater ROI by configuring customizable risk models and integrating Social Determinants of Health (SDOH) data to help prioritize member interventions.

GuidingCare gives care teams access to real-time, comprehensive member profiles that inform targeted outreach and move away from reactive risk mitigation to proactive cost avoidance. The platform’s flexibility supports rapid response to emerging risk and optimizes care team productivity, directly impacting key areas like MLR and member outcomes.

Closing the Engagement Gap with Digital Tools

Member engagement is foundational to any successful care management strategy. GuidingCare’s digital member engagement module supports HIPAA-compliant, streamlined, bidirectional communication between care teams and members. For health plans new to GuidingCare, this means integrated engagement from day one. For current customers, activating digital engagement enables real-time data sharing, symptom tracking, educational interventions, and feedback loops that inform clinical interventions, build member trust, and improve satisfaction.

Operational Agility and Regulatory Excellence

The move toward modular, integrated care management is not only about outcomes but achieving operational resilience and compliance at scale. GuidingCare’s Appeals & Grievances and Utilization Management modules are engineered for regulatory agility, automating complex processes and mitigating compliance risks without additional administrative overhead.

By consolidating disparate point solutions, health plans can benefit from streamlined data management, reduced IT burden, and enhanced agility to respond to market and regulatory change.

Real-World Member Journey: Bringing Whole-Person Care to Life

Imagine a member diagnosed with congestive heart failure who has recently been discharged from the hospital. Using GuidingCare, the care manager begins by accessing a unified, longitudinal member profile that aggregates clinical history, pharmacy data, SDOH factors, and recent hospital events.

The care manager leverages GuidingSigns Analytics to assess the member’s risk for readmission, identifying social or behavioral health barriers that might impact recovery. Through configurable business rules, the platform recommends an evidence-based, individualized care plan and initiates an automated transition-of-care workflow.

Leveraging the digital engagement module, the care manager quickly enrolls the member in daily symptom and medication adherence tracking. When the member logs new symptoms through the mobile app, this data is instantly available to the care manager, who receives a real-time alert. The care manager responds by adjusting the care plan, coordinating with primary care and specialists, and scheduling necessary virtual or home visits.

Throughout the journey, the Utilization Management module allows the coordination of authorizations and services while the Appeals & Grievances module ensures that member issues are documented and resolved with full transparency. The entire process—from risk assessment to multi-channel communication and regulatory compliance—is streamlined within the integrated platform, empowering the care manager to support better outcomes, reduce avoidable readmissions, and foster meaningful member engagement.

Your Partner for Transformation

Healthcare continues to evolve, driven by innovation, regulation, and member needs. HealthEdge® is committed to advancing care management through solutions that anticipate tomorrow’s challenges while delivering measurable ROI.

Whether you’re ready to embark on your care management transformation or seeking to amplify the impact of your existing platform, GuidingCare delivers a future-proof ecosystem for comprehensive, member-centric care.

Discover what GuidingCare can do for your organization. Read the 2025 IDC MarketScape: U.S. Value-Based Healthcare Analytics Vendor Assessment to see how our unified digital ecosystem delivers operational, clinical, and financial results.