A leading non-profit health plan company, serving over two million Medicaid, Medicare Advantage and Commercial members across multiple states, struggled with legacy systems that impacted efficiency, compliance and resource utilization. Each line of business (LoB) managed workflows independently, manually tracking data in spreadsheets and working with disconnected tools. Care managers logged into multiple systems or used email and shared drives to monitor assessments, care plans and member letters. Compliance with regulatory requirements, such as prior authorization turnaround times and outreach schedules, was done manually too, increasing the risk of missed SLAs and audit findings. Member communications relied on varied templates, causing inconsistent branding and rework, while frontline staff had limited cross-LoB visibility and flexibility.
To break down these silos and improve member experience, the client sought an enterprise-wide scale-up of HealthEdge GuidingCare, an AI-driven care management platform. It engaged Persistent to engineer and execute on a multi-LoB onboarding strategy that standardizes workflows, compliance, SLAs and data security—all while maintaining business-as-usual.
Scaling Up Without Tripping Over LoBs
The client needed:
- Multi-LoB scalability: Scale GuidingCare as a single platform, while maintaining stable operations, avoiding configuration conflicts and protecting existing LoB functionality during releases and testing.
- LoB-specific compliance control: Address varying federal, state and product-specific requirements (including state Medicaid rules, CMS requirements and commercial SLAs) by applying rules to relevant LoBs, minimizing compliance risk and avoiding cross-LoB impact.
- Configuration, roles and access alignment: Configure LoB-specific workflows, assessments, letters, care plans and queues without duplication or conflicts, while enabling staff to work across multiple business units with appropriate role-based access and separation of duties.
- User adoption and change management: Preparing SOPs, quick reference guides, training and communicating sessions to ensure adoption, productivity and readiness for ongoing platform changes across
However, approaching each new LoB as a bespoke GuidingCare implementation would lead to longer configuration cycles, overlapping change requests and increasing regression risks.
Scaling Made Simple: Reuse, Refine and Rise Up
Persistent delivered a structured rollout approach organized into phased waves by LoB and capability, spanning configuration, compliance, testing and adoption.
- LoB-specific member communication: Persistent analyzed business and regulatory user stories to define required member communications. We designed unified SMARTCOMM templates with variable-driven sections, such as business, product, state, language, member attributes, and validated data mappings from GuidingCare. Underpinning this was a rigorously tested logic for content, notices and disclaimers to ensure compliance and consistency across LoBs and states. This approach reduced the number of unique templates
- Compliance-first workflows: Persistent’s domain experts partnered with the implementation team to embed compliance into daily operations. We configured GuidingCare with context-aware workflows, regulatory controls and LoB tagging at member, case and task levels, ensuring workflows aligned with product and region. We set regulatory rules and SLAs, including Medicaid and Medicare prior authorization timelines, with countdowns and escalating alerts. For care management, we defined outreach cadences and documentation standards aligned with NCQA and CMS standards. Compliance tasks and notifications trigger only when relevant, reducing noise, eliminating manual trackers and helping the client clearly establish audit trails.
- Dual testing strategy to reduce release risk: We built and maintained a reusable end-to-end regression suite (intake to closure and letter generation) and applied manual and automated tests to validate core functions such as authorizations, referrals, assessments, care plans, tasks and reporting, cutting high-severity production defects by over 40%. In parallel, we performed targeted functional testing for each LoB’s rules, SLAs, workflows, letters and integrations, validating cross-LoB scenarios through structured business-user acceptability testing with defined entry/exit criteria and defect triage.
- Operational enablement: To drive adoption and sustainment, Persistent focused on operational readiness by defining role-based access controls (RBAC) for profiles across care managers, UM nurses, medical directors, supervisors and support staff, with LoB-specific access to protect privacy and separation of duties. We set up LoB-based queues and dashboards to give users a single prioritized worklist with visibility into workloads, SLA risks and KPIs. We monitored adoption via usage KPIs (e.g., tasks completed in GuidingCare vs. outside tools, in-platform letter generation, and time to complete key workflows) with feedback loops to refine configuration.
GuidingCare Scale-Up Boosts Productivity and Elevates Experiences
With Persistent, the client onboarded multiple LoBs on GuidingCare, achieving:
- Speed and scalability: 30% faster onboarding of new LoBs, reducing time.
- Cost efficiency: 25% implementation and run cost savings by reusing core GuidingCare configurations instead of starting from scratch.
- Regulatory compliance: Improved regulatory compliance by configuring LoB-specific rules and SLAs that reduced missed timelines and manual tracking.
- Productivity and operations: 20% improvement in staff productivity, measured as an increase in cases and tasks completed per FTE per day.
- Member and provider experience: Standardized care management workflows ensure consistent letter templates and decision communication, fewer handoffs and reduced need for members to repeat information as they transition between products.
Persistent remains engaged as a strategic partner to help the client extend the model to future LoBs, refine automation, and further enhance reporting and analytics on top of the unified care management platform.
