A nonprofit regional Medicaid health plan sought to streamline Utilization Management (UM) operations to gain efficiency and achieve cost savings. Existing workflows were heavily manual, relying on fax, email, and phone-based submissions. This fragmented approach created compliance risks, slowed turnaround times, and consumed valuable staff resources.
At the same time, the organization needed to align with updated regional regulatory requirements for electronic prior authorizations, which mandate faster turnaround times compared to traditional submission channels. To remain compliant, reduce administrative burden, and improve provider collaboration, the health plan required a strategic solution that could deliver efficiency, transparency, and oversight.
The organization engaged Anoteros as a strategic partner to lead the implementation of HealthEdge’s GuidingCare® Authorization Portal—a modern digital solution designed to automate preauthorization workflows and provide real-time communication between providers and UM staff.

Anoteros led a structured engagement designed to deliver immediate operational improvements and long-term sustainability. We implemented the Authorization Portal in collaboration with the health plan’s Utilization Management, Care Management, Provider Relations, Customer Care, Claims, IT, and Project Management teams.

• Stakeholder alignment: Facilitated cross-functional sessions to identify the health plan’s pain points, including incomplete submissions, inaccurate diagnosis and procedure codes, overlapping dates of service and provider’s lack of real-time visibility into authorization status.
• System configuration:
  • Identified authorization types eligible for online submission.
  • Designed and configured custom scripts and questionnaires to gather all required information upfront, along with the submission
  • Designed business rules to automate routing authorizations and notifications.
  • Enabled provider self-service capabilities, such as submitting prior authorizations, reauthorizations, discharge notifications, and withdrawal of pending requests.
• Regulatory compliance: Updated workflows and turnaround times to meet electronic submission standards (3 vs 5 business days), electronic notifications, while also aligning with NCQA accreditation requirements.
• Provider readiness: Created external-facing training materials, FAQs, and video vignettes to support provider adoption. Conducted live demonstrations for targeted provider groups.
• UM staff enablement: Developed internal desk-level procedures reflecting new workflows, supported User Acceptance Testing (UAT) with internal and external users, and provided Go-live support to ensure real-time troubleshooting and issue resolution.
• Integration support: Coordinated with a concurrent Provider Portal initiative to enable Single Sign-On (SSO) integration with the GuidingCare® Authorization Portal.

The Authorization Portal launched successfully with minimal provider inquiries and strong adoption. Key impacts included:

• Operational efficiency and Cost Savings: The Utilization Management (UM) department achieved notable reductions in manual effort for both administrative and clinical staff, resulting in enhanced efficiency and cost savings. Contributing factors included:
  • Reduced reliance on fax and email-based requests from high-volume providers
  • Upfront collection of all required information, eliminating the need for follow-up inquiries to Providers
  • Automated routing of requests and associated notifications that reduced supervisor triaging and case-load assignments
• Regulatory compliance: Electronic submission workflows ensured compliance with accelerated turnaround requirements, strengthened data integrity, and improved audit readiness.
• Provider experience: Providers gained real-time visibility into the status of authorization requests submitted from multiple locations according to role-based permissions, the ability to self-serve updates, and timely access to direct communication channels with UM staff—improving collaboration and transparency.
• Sustainable transformation: With standardized processes, clear documentation, and staff/provider readiness, the health plan now operates on a scalable foundation that enhances oversight and supports ongoing UM initiatives.

Through strategic partnership with the health plan and HealthEdge®, we delivered more than technology—we transformed utilization management operations to achieve measurable compliance, efficiency gains, stronger provider relationships and cost savings for the health plan.