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Data Sheet: Business and Technical Advisory Services for GuidingCare

Expertise to Strengthen Your Care Management Operations

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Business and Technical Advisory Services for GuidingCare®

HealthEdge offers Business and Technical Advisory Services for the GuidingCare® platform, providing specialized expertise to help health plans optimize care management operations. As plans evolve by adding new lines of business, responding to regulatory changes, or refining workflows, our Global Professional Services (GPS) team provides the focused guidance needed to enhance performance and move forward with confidence.

Our advisors partner with your business, clinical, and IT teams to identify root causes of operational challenges and recommend best-practice improvements. Unlike third-party consultants, HealthEdge brings deep GuidingCare expertise, direct access to product teams, and a long-term partnership model to ensure recommendations are successfully implemented and aligned with the platform’s roadmap.

Why Health Plans Engage GuidingCare Advisory Services

Health plans turn to HealthEdge GPS when they need expert support to strengthen their care management operations. Key drivers for engagement include:

  • Workflow Optimization: Expert help to improve efficiency, reduce redundancy, and align GuidingCare workflows with industry best practices.

  • Strategic Implementation: Guidance for implementing new functionality or operational changes, such as launching new programs or supporting state expansions.

  • Regulatory Readiness: Support preparing for regulatory and accreditation requirements, including CMS, NCQA, and state-specific mandates.

  • Complex System Changes: Help planning and sequencing complex initiatives, such as consolidating hundreds of work queues into a manageable, best-practice structure.

Core Advisory Services and Focus Areas

Our Business and Technical Advisory Services for GuidingCare® are designed to address the most critical challenges facing health plans today.

Workflow Optimization & Best Practice Assessments

GPS advisors evaluate current GuidingCare workflows, configurations, and user processes to identify inefficiencies and streamline operations. We conduct a thorough optimization assessment to map current usage against platform best practices.

Typical Use Cases:

  • Reducing excessive work queues for improved efficiency.

  • Streamlining utilization management, care management, or appeals workflows.

  • Improving assignment logic, configuration consistency, and SOP alignment.

  • Identifying opportunities for automation through business rules or script forms.

  • Optimizing prior authorization via the GuidingCare Authorization Portal.

For more insights, read our blog on how to optimize care management workflows with GuidingCare®.

Regulatory & Compliance Support

Our team helps plans interpret and implement evolving state and federal requirements within GuidingCare to ensure compliance and audit readiness.

Typical Use Cases:

  • Preparing for CMS and NCQA audits. Learn more in our white paper on audit preparation.

  • Implementing new state regulatory requirements.

  • Designing script forms, assessments, or business rules to meet compliance timelines.

  • Building reports and dashboards to track key compliance metrics.

  • Navigating CMS regulatory changes for care management.

New States, New Lines of Business, and Mergers & Acquisitions

GPS advisors provide the strategic planning required to expand operations or integrate systems, ensuring GuidingCare is configured to support new demands.

Typical Use Cases:

  • Launching new Medicaid, Medicare, LTSS, or Marketplace programs.

  • Supporting statewide expansions, similar to this Medicaid expansion case study.

  • Aligning workflows and processes following mergers and acquisitions.

  • Consolidating data or migrating populations onto existing GuidingCare instances.

Technical Enhancements and Integration Advisory

Advisors guide the design and planning of API configurations, interfaces, and other technical changes needed to modernize care management workflows and improve interoperability.

Typical Use Cases:

  • Adding or updating integrations with external vendors.

  • Moving from batch processes to real-time data exchange using the GuidingCare API Catalog.

  • Improving data mapping and API configurations.

  • Supporting architectural changes and interoperability needs with FHIR-driven solutions.

Our Four-Step Advisory Approach

GuidingCare advisory engagements follow a streamlined and flexible process to deliver actionable results.

  1. Discovery and Current-State Evaluation: We begin by understanding your challenges through interviews, workflow reviews, and system analysis to identify root causes and operational constraints.

  2. Best-Practice Guidance and Solution Options: Our advisors present GuidingCare best practices and outline options for improvement, including workflow adjustments, configuration updates, and rule enhancements.

  3. Recommendations and Actionable Path Forward: We deliver clear recommendations tailored to your needs, timelines, and regulatory environment, which may include prioritization guidance and effort estimates.

  4. Advisory Support Through Execution: GPS can continue to partner with your team during implementation to clarify requirements, review configurations, and validate that the final solution aligns with best practices.

The HealthEdge Advisory Team Advantage

Our multidisciplinary team brings over 100 years of combined GuidingCare expertise from more than 200 advisory engagements.

Role

Responsibilities

Principal Consultant

Leads solution blueprinting, identifies problem statements, and defines the high-level scope and approach.

Business Analyst

Analyzes functional needs, documents requirements, and oversees workflow and configuration recommendations.

Data Integration Analyst

Designs integration logic, supports API and data mapping, and ensures downstream system alignment.

Clinical Subject Matter Expert

Evaluates clinical workflows, regulatory requirements, and care management best practices.

Project/Delivery Manager

Oversees the engagement, timelines, and coordination across all teams.

 

Real-World Success with GuidingCare Advisory

  • Workflow Optimization: A national plan reduced over 200 active work queues to a streamlined structure, reducing administrative complexity and improving staff efficiency.

  • Compliance Enhancements: A customer engaged GPS to evaluate workflows for an upcoming CMS audit. Our team identified gaps and designed the required business rules and script forms to ensure audit readiness.

  • State Expansion: For a plan expanding Medicaid operations, GPS defined the solution blueprint, identified data requirements, and guided the plan through design and planning.

  • Merger Integration: Following a merger, GPS provided advisory support to analyze the combined environment and plan the migration of member data into a single, unified GuidingCare instance.