Product Guides
Risk and quality
Import plan data, work HCC worklists, track HEDIS and Stars measures, and analyze MLR financials.
Overview
The Risk Management group is the analytics suite for value-based care. It ingests plan files — eligibility, claims, pharmacy, and financials — and turns them into risk scores, quality rates, and prioritized worklists your coders and care teams act on.
The modules
| Module | What it does |
|---|---|
| Imports | Load payer files with saved mappings. Imports feed every other module in the suite. |
| MRA Analysis | Medicare risk adjustment scoring across the panel, with payment-year and blend handling built in. |
| HCC Optimization | A worklist of suspected and historical HCC gaps with a confirm-and-capture workflow for coders. |
| HEDIS Quality | Measure rates refreshed daily with member-level gap lists backed by claims evidence. |
| TRC Workflow | Transitions of care: discharges and their follow-up requirements in one queue. |
| Part D Adherence | PDC tracking that flags members drifting below adherence thresholds. |
| Financial Analysis | MLR dashboards from your financial imports: revenue, claims, and pharmacy spend. |
| Stars Rating | CMS Star measure tracking under the Compliance group. |
A typical monthly cycle
- 1
Import the new files
Load the month’s eligibility, claims, pharmacy, and funding files under Imports.
- 2
Review the dashboards
MRA and Financial Analysis update to the new period; HEDIS rates refresh daily on their own.
- 3
Work the lists
Coders confirm HCCs from the optimization worklist; care teams close HEDIS, TRC, and PDC gaps.
- 4
Engage members
Send gap lists to outreach campaigns so the phone calls happen without manual dialing.
Every figure is traceable to its underlying evidence — click through from a score or rate to the claims behind it. Outreach integration is covered in AI Voice & Outreach.