Automate enrollment processes for individual and group plans, including eligibility verification, onboarding communication, and documentation.

Track eligibility rules for members across different plans, ensuring compliance with regulatory requirements for Medicare and Medicaid.

Monitor key enrollment metrics such as time-to-enrollment and enrollment completion rate.

Target members for wellness programs and preventive care initiatives based on demographics, claims history, and clinical data.

Use CRM to manage Net Promoter Score (NPS), member satisfaction surveys, and other engagement KPIs.

Consolidate interactions, claims, and communication histories to provide a unified view of each member.

Track the full lifecycle of claims processing, including submission, adjudication, and resolution, with visibility into claim status at every stage.

Automate claims reconciliation processes to identify discrepancies and initiate claim status updates or appeals.

Streamline claim denial resolution workflows by categorizing denials, identifying root causes, and triggering necessary follow-up actions.

Manage provider credentialing workflows, including automated follow-ups for expiring licenses and certifications.

Track network adequacy metrics to ensure compliance with state and federal guidelines on provider accessibility for members.

Analyze provider contract performance, measuring contractual metrics such as adherence to clinical pathways and cost-efficiency.

Coordinate care for members with complex health conditions or chronic diseases by centralizing care management interactions and services.

Automate prior authorizations, concurrent review, and retrospective reviews to ensure appropriate use of medical services.

Facilitate communication between care managers, members, and providers to optimize health outcomes, reduce care fragmentation, and avoid gaps in care.

Use CRM analytics to identify potential at-risk members based on engagement, claims utilization, and satisfaction surveys, triggering proactive outreach campaigns.

Automate outreach to members nearing plan renewal to optimize member retention, and manage plan selection based on individual needs.

Capture and analyze member feedback, leveraging insights to improve processes and ensure positive member experiences.

Automate enrollment processes for individual and group plans, including eligibility verification, onboarding communication, and documentation.

Track eligibility rules for members across different plans, ensuring compliance with regulatory requirements for Medicare and Medicaid.

Monitor key enrollment metrics such as time-to-enrollment and enrollment completion rate.

Use CRM-integrated data to manage risk adjustment activities, stratifying members based on health conditions and identifying potential interventions.

Identify trends in high-cost claims and initiate containment activities, such as referrals to disease management programs or specialist consultations.

Track financial metrics including medical loss ratio (MLR), cost per member per month (CPM), and administrative cost ratios for performance optimization.

Use CRM-driven data to segment populations and predict the likelihood of high-cost events, helping to manage risks effectively.

Capture and analyze HRA data to understand member needs, inform care management, and identify early interventions.

Monitor claims, financials, engagement, and quality metrics through real-time dashboards to facilitate timely decision-making.

Integrate with provider EHR (Electronic Health Records) to facilitate data exchange and support utilization management and care coordination.

Integrate with claims clearinghouses for electronic claims submission and remittance advice, ensuring efficient and timely processing.

Ensure data exchange through HL7 and FHIR protocols to meet industry standards for interoperability and data flow.

Automate communication to enroll members in wellness programs, track participation, and provide proactive health interventions.

Engage members in chronic disease management programs, monitoring program adherence and outcomes to reduce complications.

Identify eligible members for preventive screenings or immunizations and trigger targeted outreach to boost compliance rates.

Provide a seamless member experience through integrated support channels, including call center, email, chat, and online self-service portals.

Automate service request routing and resolution, tracking first-call resolution (FCR) and average handling time (AHT) metrics.

Manage the lifecycle of member grievances and appeals, ensuring timely resolution and regulatory compliance.