Clinical & Care Management

Clinical and care management is a cornerstone of healthcare payer operations, directly influencing member outcomes, regulatory compliance, and operational efficiency. Matridyne’s Clinical & Care Management Services are designed to optimize every aspect of this complex and critical function, enabling payers to meet rigorous requirements while delivering exceptional member and provider experiences. From setting up, administering, and optimizing Special Needs Plans (SNPs) to utilization management (UM) and care coordination, we provide tailored solutions that drive measurable improvements.

Addressing Challenges in Clinical & Care Management
Healthcare payers face significant challenges in clinical and care management, including:

• Special Needs Plans (SNPs): Managing dual-need members under C-SNP, D-SNP, I-SNP programs requires meticulous care planning, timely assessments, and adherence to regulatory mandates.
• Regulatory Compliance: Meeting requirements for care assessments and touchpoints within prescribed timeframes is essential for avoiding penalties and maintaining high STAR ratings and NCQA accreditation.
• Utilization Management Efficiency: Optimizing UM operations—including auto approvals, timely pre-authorization processing, and concurrent reviews—reduces administrative burdens while ensuring quality care.
• Technology Enablement: Implementing and managing care management platforms like Zomega Jiva, HealthEdge GuidingCare, MHK Care Prominence®, Virtual Health’s HELIOS, and Cognizant’s Health TranZform streamlines workflows and improves outcomes.
• Delegation Oversight: Ensuring the effective delegation of clinical reviews and care management to third-party providers without compromising quality or compliance.
• Automation and Portals: Leveraging portals and automation to improve stakeholder interactions and reduce manual intervention.

Comprehensive Assessment and Tailored Recommendations
Matridyne begins with a deep dive into your organization’s clinical and care management operations. Our assessments cover people, processes, technology, and financial metrics, providing a comprehensive view of your current capabilities. We identify inefficiencies, compliance risks, and areas for improvement, synthesizing our findings into actionable recommendations that align with your goals and constraints.

Expert Pairing for Unparalleled Value
Our unique approach pairs industry experts—professionals who have managed and optimized clinical and care management functions—with advisory consultants who specialize in implementing change in healthcare payer organizations. This ensures that our strategies are both grounded in real-world experience and tailored to the nuances of the healthcare payer environment. Unlike other firms, we remain engaged through every stage of the transformation, from strategy to execution.

Enhancing Care Management Through Technology and Relationships
Matridyne has extensive experience in implementing and optimizing care management platforms, including those most commonly used in the industry. Our team leverages these tools to enhance workflows, improve data accuracy, and facilitate better coordination across teams. Additionally, our relationships with leading vendors and executive teams provide us with unparalleled access and insights, enabling us to accelerate implementations, resolve challenges, and customize solutions to meet your unique needs.

Improving Compliance and Quality Measures
Clinical and care management processes are critical to achieving STAR ratings and NCQA accreditation. Matridyne ensures that your operations meet all regulatory requirements, from timely assessments to accurate documentation and reporting. Our solutions are designed to minimize compliance risks while maximizing operational efficiency and member satisfaction.

Seamless Integration Across Systems and Processes
We understand the interconnected nature of clinical and care management with other payer operations, such as claims processing, member management, and provider engagement. Matridyne’s solutions ensure seamless integration across these functions, creating a unified ecosystem that supports better outcomes and streamlined operations.

End-to-End Engagement for Lasting Results
From evaluating third-party delegation models to building portals and automating workflows, Matridyne provides hands-on support that goes beyond high-level recommendations. We stay with you throughout the transformation journey to ensure that solutions are not only implemented but also operationalized and optimized for long-term success.

Future-Proofing Clinical and Care Management
In a rapidly evolving healthcare landscape, payers must continuously adapt to new regulations, technologies, and member expectations. Matridyne prepares your organization for the future with innovative solutions that leverage AI-driven analytics, process automation, and data-driven decision-making to enhance care coordination and management.

With Matridyne’s Clinical & Care Management Services, healthcare payers can achieve compliance, improve member outcomes, and streamline operations. By combining deep industry expertise with practical execution, we deliver solutions that drive meaningful results.

Contact Matridyne today to learn how we can help optimize your clinical and care management operations and create a lasting impact for your organization and its members. Let us be your trusted partner in transforming healthcare operations.