GuidingCare: Case Studies & Insights

The client, a national payer with Medicaid and Commercial lines of business, had targets to expand into new Medicaid markets but was beleaguered by operational limitations. The care management and utilization departments’ clinical workflows were heavily manual, as they had to work across seventeen disparate systems. Nurses couldn’t effectively access and update member records when in the member’s home, and several compliance gaps had been identified. The client had purchased HealthEdge®’s  GuidingCare® care management platform and hired a multi-billion-dollar consulting firm to plan and execute the implementation, but after several months the project was at a standstill, with the stakeholders unable to agree on the priorities for implementation.

Due to our track record of successful GuidingCare® implementations and our understanding of the business change approach needed for this platform, Anoteros was hired to replace the first consulting firm and we pivoted the project from a technology implementation to a clinical transformation for the payer. We worked to quickly understand the compliance and operational needs of the clinical teams and used that input to develop a phased implementation roadmap. The first release focused on a Minimal Viable Product (MVP), meeting the essential needs of all clinical teams and enabling the client to retain membership in their current market. Subsequent releases would add automation and efficiency gains, enabling the payer to expand into newer markets. We also mapped dependencies with the client’s other transformation initiatives and the GuidingCare® product roadmap. Instead of telling the stakeholders what they should do, we worked to understand their needs and concerns and used that to inform the roadmap. With all stakeholders now on board, the client – with Anoteros’ help – was able to move forward with implementation.

The transformation consolidated clinical operations from seventeen systems to one, automated key clinical workflows, provided mobile capability for nurses’ home visits, and enabled payer-provider collaboration using portals. As a result, the plan was able to reduce its compliance gaps by 75% and increase staff productivity by 40%. These improvements enabled the payer to secure its current market position and expand into new markets. The client called Anoteros “the key reason for the successful transformation of their clinical operations.”

The client, a health plan offering Medicaid plans in the Midwest, had launched the implementation of HealthEdge®’s GuidingCare® platform. Unlike its legacy care management system, GuidingCare® would allow integration with other applications, workflow automation, and importantly, the ability to easily scale and therefore support the health plan’s goal of expanding into new markets. Unfortunately, the legacy system vendor was not willing to participate in this transition and instead opted to provide raw data extracts of the client’s clinical records without documentation on the data model.

Anoteros was hired to migrate the data from the legacy system to GuidingCare®. We tapped into our deep healthcare payer experience, knowledge of care management, and expertise in data and technology. We brought together a team of data and business analysts, developers, and a project manager. The team hit the ground running, quickly learned the data model of the legacy system, and developed a data migration and archival strategy. The strategy not only included the steps to migrate data into GuidingCare® but also included steps to address the front-end and workflow impacts once the data was migrated into GuidingCare®. Our team created the data mapping specifications, developed the data migration routines, performed system testing, and facilitated the user acceptance testing of the migrated data in GuidingCare®.

The data migration was successful and supported a seamless transition between care management platforms for the end-users. The data archival strategy positioned the health plan to easily respond to future audits. Overall, the data migration allowed the client to complete the implementation project and turn their focus to expansion efforts.

Anoteros brought such strong expertise in health plans and the GuidingCare product — I didn’t even know there were consultants who could do that”
— Director of Care Management

Our client, a nonprofit Medicaid insurance provider serving over 400,000 members, approached Anoteros with significant operational challenges with its care management systems and processes. The organization’s Care Management and Care Coordination teams were struggling with complicated processes that prevented them from fully utilizing the capabilities of their care management system, HealthEdge®’s GuidingCare® care management platform.

The Care Management team was burdened by over 50 workflows that lacked standardization and were cumbersome to navigate. This complexity forced staff to document patient interactions outside the system and later transfer information, creating duplicative work and inefficiencies. Documentation primarily consisted of free-text notes, resulting in high variability and difficulty tracking outcomes through structured data collection. These limitations also hampered reporting capabilities needed to drive improved productivity and quality of care.

Additionally, with NCQA accreditation as a strategic goal, the client needed to ensure their operational processes met accreditation requirements while establishing a solid foundation for compliance

Drawing on our extensive knowledge of GuidingCare® functionality and care management best practices, the Anoteros team began with a comprehensive end-to-end review of all existing workflows, state contracts, and supporting documentation. During the Discovery phase of the project, we analyzed the information provided by the client to identify efficiency opportunities and system capabilities that could support more streamlined processes.
Our analysis also focused on identifying improvements needed to achieve NCQA accreditation and ensure compliance with relevant federal and state regulations. Working collaboratively with the client, we documented and reviewed suggested process changes and completed the system configuration necessary to implement previously unused
functionality. These enhancements added structure to workflows, improved guidance for staff, and created simplified methods for collecting member information in a structured format.

The Anoteros team developed comprehensive desk-level procedures and supporting materials that not only guided the client through implementing the new workflows but also served as valuable training resources for both current and incoming staff. We conducted comprehensive testing alongside the client to ensure the system performed as expected and met end-user requirements.

We shared industry best practices for post-implementation system management and established processes for the submission, review, and implementation of user-requested changes. To support a successful launch, our team assisted in configuration promotion between the lower and production environments and provided monitoring after go-live to ensure users had the knowledge and tools needed for their daily activities under the new workflow system.

The Care Management optimization transformed how the client’s teams operated. By consolidating over fifty workflows into just sixteen, we dramatically simplified how staff carried out their daily activities. Clinical staff gained the ability to improve documentation practices through structured data entry, reducing their reliance on lengthy narrative notes and improving the speed and efficiency of documenting member interactions and outcomes.
These improved practices significantly increased standardization in care management processes, enhancing the organization’s ability to report on outcomes and staff productivity while monitoring quality of care. The structured approach also positioned the client for greater success in achieving NCQA accreditation by aligning workflows with industry best practices.

Ultimately, the partnership between Anoteros and the client resulted in more efficient operations, better documentation, improved reporting capabilities, and enhanced care management for the 400,000 members served by this Medicaid insurance provider. By optimizing their GuidingCare® platform and associated workflows, Anoteros helped the client build a stronger foundation for continued growth and improved member services.

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.