Leverage powerful risk analytics

Improve risk adjustment scoring and care gap closure through powerful analytics spanning all managed care lines of business.

Risk Adjustment

Managed care plans face the multi-headed monster of attempting to ensure accurate risk-adjusted revenue while improving intervention planning and closing coding and care gaps. However, these same plans are often plagued by disjointed systems, a lack of real-time intelligence and overall poor risk insight. These factors contribute to reduced risk-adjusted revenue, poor intervention planning and an increase in coding and care gaps.

Our Approach

Edifecs Risk Adjustment delivers a comprehensive risk adjustment analytics platform designed to handle the complexity of differing risk adjustment models across managed care programs. Real-time intelligence ensures up-to-date insight into population risk factors while actionable program analytics seek to reduce coding and care gaps. Dynamic intervention planning prevents wasteful expenditures on ineffective interventions.


Member insight

Integrate with Edifecs Encounter Management for enhanced member insight and submission accuracy.

  • Enable end-to-end tracking and visibility into member claims and chart review data.
  • Streamline Medicare Advantage, managed Medicaid, dual eligible and Marketplace submissions and reconciliation to improve first-pass rate accuracy, visibility and tracking.
  • Leverage state-specific managed Medicaid encounter modules, complete with companion guides and business rules, to address individual state requirements.
  • Operationalize configurations to support both dependent and non-dependent “duals” models across states.

Positive financial impact

Enhance the financial impact and intervention effectiveness of your risk adjustment analytics.

  • Generate customized member profiles and risk scores derived from risk adjustment diagnosis incidence rates.
  • Evaluate incidence rates by both a persisting and suspecting incidence rate to determine risk factor impacts.
  • Improve the targeting of suspect claims and provide reporting to optimize specific risk adjustment interventions.
  • Deliver timely decision support to enable the closing of care gaps and achieve optimal program performance.

Predictive analytics

Analyze traditional claims data, along with real-time data and patient-reported data, to make predictions about what individual members will require.

  • Analyze populations more objectively and independently to improve population health insight.
  • Manage interventions with speed and accuracy to improve care deliver effectiveness and member outcomes.
  • Avoid unnecessary interventions with Dynamic Intervention Planning to enhance program financial performance.
  • Enable real-time visibility into member and provider behaviors through transparent and flexible business intelligence tools.