Top 5 Medicaid MSO

The Challenge

Managed Medicaid is an extremely competitive market. To remain at the forefront and secure additional state Medicaid contracts, the health insurer needed a significant edge. Outdated provider data management and credentialing technology strain operational efficiencies amidst rising government mandates for data accuracy in health plan operations. Recognizing the urgency to stay ahead, our client proactively embraced change.

The solution required a modern, end-to-end provider network management system to enhance data quality, accelerate processing times, and meet stringent regulatory requirements. The payer’s reliance on legacy credentialing systems and multiple claims systems made transformation imperative. Siloed, outdated practices proved resource-intensive and hindered compliance with provider credentialing timelines.

After careful consideration, the organization selected V12 Network Pro, an enterprise provider network application built on the Salesforce platform. Integrating with their existing member management system allowed real-time synchronization of provider data across teams, ensuring the utmost accuracy and efficiency.

The Solution

The integration of Einstein with V12 Network Pro on Health Cloud provided real-time provider data updates, empowering our client to make informed decisions in member and provider call centers. This advanced setup streamlined provider network management, while enhanced data accuracy, combined with Einstein analytics, enabled quicker and more accurate responses to claims, payments, and benefits inquiries.

The Virsys12 team played a pivotal role in transforming the payer’s provider data architecture, moving away from outdated systems unable to effectively link providers to practices, specialties, and networks. V12 Network Pro established a seamless flow of inbound and outbound data, offering a comprehensive view of provider profiles. Additionally, it enabled critical downstream integration with the organization’s claims system, ensuring provider demographics and network contract statuses remained accurate and up-to-date.

The implementation also introduced streamlined provider credentialing workflows and ensured adherence to government regulations surrounding contracting with qualified providers. Integration of OIG Exclusion monitoring and real-time API interfaces to CAQH ProView and ProviderTrust allowed the payer to meet these goals effectively.