Product Guides
Risk Adjustment & 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.