Largest Not-for-Profit Health Plan Serving The Mid-Atlantic

The Challenge

In the ever-evolving landscape of healthcare, a leading not-for-profit health plan serving 3.5 million individuals in the mid-Atlantic region faced a critical crossroads. With outdated provider data management technology and increasing government mandates for data accuracy, the organization found itself grappling with:

• Manual, siloed processes draining valuable resources
• Operational inefficiencies threatening regulatory compliance
• Fragmented data across departments, hindering visibility and decision-making

The stakes were high: without a comprehensive overhaul, the organization risked falling behind in an industry where data accuracy and efficiency are paramount. Recognizing that incremental changes wouldn’t suffice, the health plan embarked on a bold journey to revolutionize its provider data management. Their vision? A cutting-edge system that would:

• Unify data management across the entire organization
• Enhance interoperability between systems
• Proactively resolve provider network issues before impacting claims
• Set new standards for operational excellence and regulatory compliance

The Solution

Enter a groundbreaking partnership with Virsys12 and the implementation of the V12 Network Pro package, this powerful combination delivered:

1. A 360-Degree Provider View: A comprehensive profile for each provider, ensuring accuracy across Medicare, Medicaid, and commercial plan offerings.
2. Real-Time Credential Verification: Seamless API integrations with CAQH ProView, Sanctions Track, and VeriFide streamlined the credentialing process.
3. Intelligent Workflow Automation: Leveraging Salesforce’s Health Cloud, Shield, Connect, and Einstein Analytics to optimize provider lifecycle management.
4. Unified Data Source: Eliminating silos and boosting data accuracy across the organization.
5. Scalable and Flexible Architecture: Built on the robust Salesforce Platform, enabling swift adaptation to evolving regulations and business needs.