Integrated and analytic-driven care management drives higher quality and cost outcomes

CareRadius™ is an integrated care management platform, informed with analytics and driven by advanced digital and automation technologies.

The platform enables transparency across the care continuum, giving health plans quick and seamless access to real-time data that enhances clinical decision-making, drives quality, improves workflows, reduces administrative costs, and enables effective medical cost management. This single, integrated platform enables health plans to manage all care management functions, including utilization management and case management within a population health framework.

Proven outcomes

CareRadius™ is a proven care management platform that is used to enable efficiencies and compliance, medical costs, appropriate care settings, clinically aligned decisions, and timely referrals to case and disease programs, across all care management functions.

Average years as a customer 6+

Engagement Improved by 27% for case management

Engagement Improved by 38% for chronic disease management

Meeting target turn-around times 95% for utilization management

Create more intelligent care management operations

The CareRadius™ platform can be used to perform utilization management, case/ disease management, and population health programs across all lines of business. The platform is capable of ingesting and consuming data from virtually any source and makes sense of that data to create meaningful, actionable insights for all users.

The system creates a unique Member 360 Profile of members, which includes medical claims, pharmacy claims, lab, biometric, program enrollment, and EMR data, as well as robust medical, behavioral and social determinants of health (SDOH) information. The comprehensive member profile is used across care management functions to meet member needs, drive personalized engagement, and ensure quality and cost outcomes.

Analytics and digitally enabled workflows

Analytics and digital technologies are one driving force behind intelligently-run care management programs.

• Advanced analytics inform many aspects of care management programs, including program design and performance for optimal return on investments. Additionally, the CareRadius™ platform is embedded with advanced population analytics that drive highly focused and effective case/ disease management programs.
• Digital technologies support a health plan’s needs to do more with less. Through a wide variety of innovative digital technologies, including natural language processing (NLP), artificial intelligence (AI), and machine learning, CareRadius™ is able to automate processes and reduce manual and labor-intensive workflows and tasks.

Flexibility & compliance to meet client needs

CareRadius™ is a highly flexible and configurable platform that provides health plans the opportunity to leverage standard or custom workflows and rules based on the needs of their organization. The platform’s out-of-the box capabilities enable health plans to meet all regulatory, accreditation and audit standards for easy and streamlined compliance.

Transparency across key stakeholders and programs

Whether CareRadius™ is used across all care management programs or for just one, the platform brings significant transparency, collaboration, and coordination to care management teams. This transparency allows for early identification and referral of members to case management. Team-based collaboration around individualized member care plans, milestones, goals, and interventions facilitates faster time to outcomes for members and most effective cost management.

Smarter methods for member and provider engagement

CareRadius™ works smarter to make sense of the data. Using an omnichannel approach, the platform gathers effective insights from the captured data – like provider behavior, overturned clinical decisions, network adequacy, engagement with care programs, RX compliance, and more – to ensure health plans reach members at the right time, with the right message, over the right channel, and achieve the best possible outcomes.

Core platform components

Utilization management

The CareRadius™ platform helps to ensure effective use of healthcare resources while meeting required quality, compliance, and accreditation standards. Seamless and digitally-enabled workflows create efficiencies across operations and supports and automates the full authorization lifecycle - from requests for review, to correspondence with members and providers, all the way to grievances and appeals.

CareRadius™ can be used to perform utilization management services across medical, behavioral, and/or pharmacy, as well as across all lines of business. Industry validated and evidence-based guidelines and workflows are embedded within the platform to create the greatest level of efficiencies and compliance.

The platform also makes interaction seamless – with digital, automated intake options, portal tools, and automated letter and notification options – it’s never been easier for providers to interact with health plans. Additionally, the experience for end users is front and center. With a centralized system, automation to speed up case review and documentation details, robust reporting capabilities, and even an automatic “to do” list creation, CareRadius™ makes sense of the data to optimize and simplify user experience.

Ensuring efficient and compliant UM operations

• Real-time auto approval based on pre-configured or client-defined rules, with automated tasking/routing for authorizations that cannot be auto-approved
• Ability to receive authorization requests via phone, fax, mail, or provider portal (client owned-or EXL’s CareAffiliate™ portal)
• Enhanced efficiencies through digital intake automation, auto-approvals, automatic tasking, and provider gold card status
• Integrates with both MCG Health, LLC CareWebQI criteria guidelines and Change Healthcare’s InterQual Connect Medical Review Service, for criteria based assessments. In order to support the decision process, the platform enables criteria assessments (third-party or internally created modeling the client’s policy) directly within the system.
• Analytic insights create more intelligent operations by identifying opportunities to optimize UM pre-authorization lists and ensure resources are focused on areas delivering the greatest ROI

Case management and population health

CareRadius™ provides end-to-end case management workflows to support health plans in their mission to meet the clinical, social, and behavioral needs of vulnerable populations while significantly improving quality outcomes and reducing medical costs.

These workflows facilitate assessment, care planning, care coordination, and advocacy for targeted members throughout the continuum of care, consistent with accreditation standards and professional standards of practice.

Integration with digital technology solutions improves the efficiency of outreach efforts and supports personalized engagement, enabling clinical staff to practice at the top of license.

The platform can support expansive program capabilities, including specialty case management programs, transitions of care, and chronic condition management. It can also manage members across all lines of business and across medical and behavioral case management.

Member 360 profile

Through robust and comprehensive data integration, aggregation, and management capabilities, CareRadius™ provides a single environment for all members of the care team to collaborate on the delivery of care. Users will share the same complete view of the patient, a single unified care plan, and stay up to date on all status and activities involving the member, including medical, behavioral, and social determinants.

Driven by embedded proprietary population analytics

Embedded descriptive, predictive, and prescriptive analytics provide clear transparency into segments of the population that will greatly benefit from specific care management programs. Proprietary risk and stratification models allow users to go beyond basic risk stratification by not only finding high-risk members, but also identifying impactable members based on their compliance with clinical measures.

And, these members aren’t just listed. CareRadius™ displays these members in an integrated and actionable way, actually starting cases and populating tasks for care managers with suggested interventions. Additional views can be layered on, including social determinants of health, to gain a full view of a member’s risk and inform on the most effective engagement strategies for that individual member.

Embedded analytics deliver significant insight to case and clinical teams:

• Emerging clinical/financial risk
• Analytics & stratification
• Member analytics
• Gaps in care and HEDIS measure
• Impactability and intervenability
• Care management program analytics
• SDOH barriers/ consumer segmentation
• Program outcomes

Robust and actionable reporting and dashboards

The CareRadius™ suite of numerous out-of-the-box and actionable dashboards equip front-line staff, managers, and executive leaders with near real-time insight into current performance, including the ability to:

• Track and ensure productivity at an individual user level
• Monitor volumes and case loads
• Prepare for audits
• Meet regulatory and accreditation compliance
• Help improve member health and cost outcomes
• Prioritize & most effectively engage with members
• Monitor the end-to-end lifecycle of an authorization request

The platform’s standard dashboards are ready to go out-of-the-box but are also highly customizable to meet specific client needs.

Operational and performance reporting: Track, trend and monitor performance to ensure target outcomes are met and adjustments to operations can be made quickly.

Compliance reporting: Ensure federal/ state regulatory requirements are met while preparing for accreditation and regulatory audits.

Population health reporting: Allow for quick and accurate identification and stratification of populations based on actionable care gaps in order to design and implement the most effective care programs.

Outcomes reporting: Evaluate program performance and understand the ROI of implemented programs.