Lowering Health Plan Costs Through Effective Care Management 

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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