CareRadius™ platform fully integrates and automates workflows

Large, U.S. regional health plan improves reporting capabilities, increases member engagement, and boosts star rating from 3 to 4.5

The challenge

A large, regional U.S. health plan with $2.6 billion in revenue interacts with various audiences such as employer groups, regulatory agencies, healthcare practitioners, and more than 600,000 members including those who are insured through employer groups, self-insured, or on Medicare Advantage or Medicaid.

The health plan’s existing system was a collection of separate software applications for each area in their care management program, and it lacked integration due to its current configuration.

For instance, there was no easy way for the health plan to produce reports requested by their employer groups, such as a report that showed all aspects of a member’s history.

The health plan was seeking a management system that provided a 360-degree member view and offered full integration across all care disciplines. They wanted to streamline and automate workflows, enhance collaboration, and efficiently provide reporting required by their employer plans and regulators.

The solution

The health plan implemented CareRadius™, a web-based care management solution that supports integrated care delivery by providing real-time insights across health plans, practitioners, and third-party care teams. The solution combines and shares multiple external disparate data sources, enhancing clinical decision-making, improving workflows, and reducing administrative costs. The solution is delivered by EXL Health, a team of clinicians, analytical experts, and care management technologists with a strong knowledge of the healthcare landscape in the United States.

Open architecture allows self-configuration by the health plan. CareRadius™ is based on flexible, open architecture that allowed the health plan to configure customizations and integrations as needed, both now and as future needs evolve. System configurations and reporting can be developed by business teams, rather than requiring input from IT for simple changes. The health plan’s team could self-configure the system using their own business rules for data validation, automated processing and workflow routing.


Improved case management process and increased member engagement rate. With CareRadius™, the health plan significantly reduced the time to identify and load new care management cases, which led to a substantial increase in member engagement. Prior to CareRadius™, the health plan’s engagement rate with members contacted for case management was 30%. Historically, case managers would not learn that a member had been admitted to a hospital and discharged to home sometimes until days after the event had occurred. This was due in part because reports were manually run using historical data and then manually loaded, which required weeks of processing time.

With CareRadius™, the health plan’s care managers now are alerted when a member is admitted and also when that person discharges.. Cases now are identified and auto-created within minutes, allowing outreach to a member on the same day as identification. This allows care managers to collaborate with other resources on the healthcare team to determine discharge planning. Today the health plan’s member engagement rate is 70% and transition-of-care outreach occurs within 24 hours of a member being discharged.

The organization now has the ability to designate fields specific to regulatory requirements, with little to no IT input.

Dramatic change in reporting capabilities and timeliness. With CareRadius™, the health plan now is able to produce comprehensive and integrated reporting. This includes both standard out-of-the-box reports and self-configured reports developed by the health plan.

The organization now has the ability to designate fields specific to regulatory requirements, with little to no IT input. Moreover, reporting accuracy has increased because the team is no longer pulling data from multiple, disparate resources. The time to run reports has dramatically reduced from one year to one day. This significant improvement in reporting has been recognized by the health plan’s employer groups, increasing their customer satisfaction and retention levels.

Significantly increased regulatory compliance. CareRadius™ includes an out-of-the-box solution to simplify regulatory compliance reporting processes. The solution features real-time integration with core enterprise systems and the Center for Medicare and Medicaid (CMS) Medicare Part D compliance reporting. Routine auditing and monitoring capabilities allows managers and the compliance department to identify and address issues immediately, preventing repeat errors.

Prior to CareRadius™, the health plan frequently had a corrective action plan (CAP) in place. Today, with CareRadius™, the health plan has been consistently compliant with all regulatory requirements, with no action plan needed. CMS audits have been reduced from 1.5 months to three days. The National Committee for Quality Assurance (NCQA) case management audit has been reduced to one day.

Health plan increased star rating from 3 to 4.5. The CMS star rating helps members and their families compare plan performance and quality for various Medicare plans. These rating are on a scale from 1 to 5, with 5 being excellent. The health plan moved from 3 or average to 4.5, good to excellent. For the health plan, a high star rating also affects CMS reimbursement rates for member services, so a higher rating equates to increased revenue for the health plan.

Improved member health and enhancing the member experience. By using the CareRadius™ solution for care management, the health plan was able to drive better outcomes to improve the quality of care and the member experience. CareRadius™ delivers a holistic view of the member, allowing practioners to create personalized care plans and deliver earlier interventions to improve member health outcomes. For the health plan, they achieved a 15% reduction in behavioral health re-admission rates and a 20% reduction in medical re-admission rates for their members.