Who we serve · Health Plans
Keep members served, claims moving and audits clean.
Clinical review, claims and member operations for Medicare and Medicaid plans, staffed by healthcare-trained teams who learn your policies and work inside your systems.
Built for health plans
Common pressures
Sound familiar?
These are the challenges health plans bring to us most often. Each one has a team built to solve it.
Medical management
Reviews and care that control cost.
Clinicians who apply your medical criteria and coordinate care across settings.
Utilization Management
Evidence-based review with eligibility and benefits verified first.
- UM intake, inpatient and outpatient
- Prior authorization reviews
- Inpatient concurrent review
Case Management
Hospitalizations, discharges and transfers, coordinated with PCPs.
- Member discharge oversight
- Authorization numbers and case notes
- Hospital and SNF transfers
24/7 Nurse Triage
A licensed nurse whenever members need one, in their language.
- Self-care advice
- Treatment option guidance
- ED vs. business-hours decisions
HRAs and Risk Adjustment
Accurate baselines and risk capture across your membership.
- HRAs at enrollment and annually
- After any transition of care
- Risk adjustment support
Plan operations
Faster claims. Happier members.
High-volume administrative work handled accurately, on time and to your policies.
Claims Processing
Review, validation and adjudication aligned to payer guidelines and benefit plans.
- Payment determination and remittance advice
- Denials and adjustments with EOBs
- Turnaround and denial-rate tracking
Member Services
Inbound, outbound and after-hours support in multiple languages.
- Member inquiries and navigation
- After-hours calls
- Post-campaign evaluation
Enrollment and Eligibility
Member data processed on time, ready for every interaction.
- Enrollment processing
- Eligibility processing
- Ongoing data entry
QuickCap Operations
Real-world payer experience on QuickCap for Medicare and Medicaid plans.
- Claims adjudication and capitation
- Care coordination workflows
- EDI and reporting
Network and quality
A compliant network. Measurable quality.
Credentialing, provider engagement and population health that move your quality scores.
Credentialing
NCQA-compliant from primary source verification to ongoing monitoring.
- Initial and 3-year recredentialing
- Committee support
- SAM, OIG and preclusion monitoring
Provider Relations
Engagement and training for the providers in your networks.
- Regular communication
- Regulatory and compliance training
- Business development
Population Health
Care coordination, disease management and data-driven outreach.
- Health coaching and care coordination
- Disease management
- Nurse advice line
Quality and HEDIS Support
Verification and outreach that help members get needed screenings and follow-ups.
- Screening and follow-up scheduling
- Benefit verification
- Smooth claims for preventive care
Results for health plans
Proven with plans like yours.
Regional health plan · 180,000+ members
Health Plan
Our clinical and administrative teams grew with this plan from 3,000 to more than 80,000 members, saving an average of $2.2 million a year in labor costs.
FAQ
Health plan questions, answered.
Have a question we did not cover? Add it to your support plan request above, or call us at (833) 335-6270.
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