Our client is a leading healthcare insurance provider serving millions of members across Medicare Advantage, ACA, and employer-sponsored plans. Their mission is to improve patient outcomes while keeping administrative overhead low, a goal made harder by rising compliance complexity, high claim volumes, and increasing pressure from regulators to deliver accurate risk scores and audit-ready processes.

The insurer’s operations were being strained on multiple fronts:

• • Fragmented Data Ecosystem: Clinical, claims, and member data were spread across multiple systems, limiting visibility and making interoperability a challenge.
• • Manual Risk Adjustment & Coding: Hierarchical Condition Category (HCC) coding and reconciliation were partly manual, creating delays and inaccuracies in CMS submissions.
• • Inefficient Revenue Cycle: Billing and claims reconciliation involved heavy manual effort, resulting in denials, rework, and revenue leakage.
• • Regulatory Pressure: The client needed HIPAA-compliant, auditable workflows to withstand CMS and state-level audits without last-minute fire drills.

NuWare designed and delivered a comprehensive healthcare operations modernization program with three key pillars: data interoperability, intelligent automation, and compliance-first design.

EHR & Data Interoperability
We built secure, API-driven integrations between EHR systems (Epic, Cerner) and payer platforms, enabling seamless flow of clinical data into claims and care management systems. The result was a single, governed source of truth for member health data, compliant with HIPAA and HITRUST frameworks.

Risk Adjustment Modernization
NuWare implemented a predictive risk adjustment framework to improve HCC coding accuracy. Automated validation and reconciliation workflows ensured risk scores were complete and timely, reducing penalties and boosting reimbursements. Predictive models flagged gaps proactively, allowing teams to address them before submission deadlines.

Revenue Cycle Automation
Through RPA and workflow orchestration, we automated claims reconciliation, denial management, and exception handling. Cloud-based dashboards provided real-time visibility into revenue cycle performance, allowing faster decision-making and better cash flow management.

Compliance & Governance
We embedded security and compliance controls into every layer, from identity and access management to audit logging and reporting, ensuring the client could demonstrate full regulatory alignment at any time.

The initiative delivered significant, measurable improvements:

• • Faster CMS Submissions: Risk score processing time dropped by 40%, improving compliance with CMS timelines.
• • Higher Coding Accuracy: Automated reconciliation and predictive gap detection improved coding completeness and increased reimbursement accuracy.
• • Reduced Administrative Costs: RPA eliminated thousands of manual hours annually, cutting operational costs and error rates.
• • Improved Member Experience: Faster claims adjudication and fewer denials led to improved member satisfaction and trust.
• • Audit-Ready Confidence: The client passed external audits with zero major findings, reducing regulatory risk exposure.

The client’s operations team shared that they now spend less time chasing data and reconciling errors, and more time focusing on strategic initiatives such as improving member engagement and wellness program adoption.

NuWare continues to support the client in expanding AI use cases, including NLP-driven clinical insights, fraud detection models, and predictive analytics for population health management, as part of their long-term digital health strategy.

Key Highlights

• • Industry: Healthcare Insurance
• • Services Delivered: EHR Interoperability, Risk Adjustment Analytics, RPA for Claims & RCM, Compliance & Governance
• • Business Outcomes: 40% faster submissions, higher coding accuracy, reduced costs, improved member satisfaction
• • Technologies: HIPAA-Compliant Cloud, RPA Tools, Predictive Modeling, API-Driven Interoperability, Secure Data Pipelines