Clinical Edge
Appeals & Grievances
Appeals and Grievances, part of Clinical Edge, simplifies complex workflows and unifies real-time data to speed timely resolutions, support compliance, and reduce administrative burden.
Talk to an Expert
End-to-End Workflow
Consolidate appeals and grievances into one guided workflow that drives every case through each resolution step, with clarity and accuracy across all reviewers and levels.
-
Consolidated processing
-
Connected workflow
-
Fewer disconnected steps
Advanced Configurability
Tailor templates and workflows to each appeal or grievance type, with configurable turnaround times that keep every case consistent and compliant with regulatory demands.
-
Configurable templates
-
Regulatory-aligned workflows
-
Configurable turnaround times (TATs)
Automated Compliance Tools
Stay audit-ready with one-click packet and PDF creation, auto-generated correspondence, and CMS Universe reports that streamline tasks and reinforce compliance.
-
One-click packets and PDF creation
-
Auto-generated docs and correspondence
-
Audit-ready
Clinical Edge Suite
Care
Management
Streamlined workflows and centralized member data help care teams deliver personalized, evidence-based, whole-person care.
Utilization
Management
Clinically sound, workflow-driven tools with intelligent automation optimize the authorization lifecycle and support compliance.
Appeals
and Grievances
An intuitive, end-to-end solution consolidates appeals, supports regulatory compliance, and delivers one-click packet creation.
Authorization
Portal
End-to-end workflows, automated approvals, and real-time provider communications boost operational agility across your plan.
Mobile
Clinician
Secure mobile access lets field staff run assessments, build care plans, capture consent, and start referrals online or offline.
Member
Engagement
A scalable digital platform pairs omnichannel communication with advanced tools to deliver measurable health outcomes.
Population
Health
Real-time analytics and effective stratification identify at-risk populations and help your teams close care gaps faster.
Quality360
NCQA-certified quality management links HEDIS gap identification to care workflows, streamlining closure and reducing manual work.
Business Intelligence
Advanced reporting and dashboards for CMS and NCQA give your teams the insight to drive smarter, data-backed decisions.
Clinical Edge
University
24/7 access to module-based training, so staff can build product expertise on their own schedule, from anywhere.
Audit-Ready Appeals & Grievances
GuidingCare Appeals & Grievances keeps health plans compliant and audit-ready with automated documentation.