BACKGROUND

When Health care insurance companies / Health Plans (HPs) insure members, the only way they make money is by having low Medical Loss Ratio or MLR. What it represents is the ratio of the money coming in from revenue such as premiums versus the money going out mostly in form of payments to health care providers. In order to keep MLR low, one area where HPs really need to focus is having healthier population since they will be using less services but paying same amount of premium. Keeping the population healthier proactively and engaging with them is essentially Care Management. For Medicaid and Medicare, HPs are required to be compliant to the requirements from CMS (Center for Medicaid and Medicare Services). In addition to meeting those requirements, HPs can also track their own performance on how they are engaging with their healthy or unhealthy population and members.

Care Management is a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It also encompasses those care coordination activities needed to help manage chronic illnesses and diseases. HealthRules Care Manager is HealthEdge's solution to this domain as a full fledged capabilities for Care Management.

BUSINESS PROBLEM

The Care Manager product has been becoming legacy in terms of technology and user experience. The flows are archaic and experience is ineffecient broken in many places. The application is click heavy and usability is way under par since parts of underlying technology is not scalable. Implementation and upgrades take a lot of time and often result in User errors due to poor and cluttered UI.

SOLUTION

The following diagram explains my overall UX strategy to solve this mess:

While the project is now in Agile UX-Dev phase, I did large amount of research ahead of the large project kick-off. This provided key guidelines on how to approach each feature being revamped.

MY ROLE

I devised the complete UX strategy to direct a better UI and UX on the existing product. I was brought in revamp the experience while the technical underpinnings were fixed and UI was revamped. I designed modules and specific features such as full Utilization Management flow, Member Dashboard, Appeals, Grievances, Medications, Notes and Tasks. Below are some key designs:

AUTHORIZATIONS / UTILIZATION MANAGEMENT

One of the two pillars of the Care Management, Utilization Management involved authorizing services based on medical necessity. The view below is a working view of a full authorization. Focus has been on clear affordances and call to actions so that back office nurses do not have to think a lot and scan around a lot to do their job.

MEMBER 360

This is an all in one view of the member. User can add widgets which are portlets of information and make a customizable view.

BENEFIT PREDICTOR

This flow helps a UM nurse determine the remaining benefits left with the member. This feature integrates with the claim system and was very complex to design. Extensive Usability testing was done for this.

PROVIDER SEARCH

This design sits on top of a new micro-service that uses Elastic search for searching across millions of provider records.

NOTES

The following functionality is used in taking Notes throughout the application. Notes are generated from various sources but need to be accessible quickly.