HealthEdge GuidingCare is a comprehensive, modular care management software solution suite designed for healthcare payers and providers to operationalize an evidence-based, person-centered care strategy. The platform, originally developed by Altruista Health (acquired by HealthEdge), is one of the largest and most widely adopted of its kind in the United States.
Product Overview & Key Benefits GuidingCare leverages next-generation data integration, sophisticated data analytics, and workflow management tools to streamline coordination across the care spectrum, improve health outcomes, and ensure compliance with evolving standards. It supports whole-person care by combining clinical, social, behavioral, and economic insights into a comprehensive system, empowering care teams to provide customized, person-centered care.
Main Features & Capabilities The solution suite includes several mission-critical clinical workflow modules:
- Care Management: Streamlines clinical workflows and care coordination, aligning with NCQA standards and CMS guidelines.
- Utilization Management: Effectively manages the authorization lifecycle with advanced tools, integrating clinical guidelines (like MCG and InterQual) and AI-driven workflows.
- Population Health Management: Features advanced gaps-in-care analytics to identify high-risk members, prioritize interventions, and optimize health outcomes, supporting measures like HEDIS and Star ratings.
- Appeals & Grievances: Automates workflows to maintain compliance across multiple lines of business and meet regulatory timelines. [cite: 9 from Search 1]
- Authorization Portal: Provides a modern, user-friendly solution for providers to manage preauthorization, messaging, and appeals.
- Business Intelligence: Tools to evaluate, track, and measure outcomes, manage operations, and stay compliant.
Technical and Compliance Highlights The platform is built on a foundation of seamless interoperability, unified under FHIR standards, and offers over 125 Pre-Built APIs for secure, real-time data sharing. It is a cloud-based, SaaS solution and is supported by a mobile clinician app for field-based staff. [cite: 3, 10 from Search 1] Compliance is a core focus, with certifications including HITRUST, NCQA Prevalidation, and AA Certification for HEDIS Measures Subset.
