Case Studies

Accountable Care Organization

Business Need: Create a Sharable platform to support data exchange across multiple provider organizations

Encourage physicians and hospitals to coordinate care

Provide data to EDW for Members, Providers and Claims

5 Sources with 30 + Source Files (Daily and Monthly)

Create extract views to send data to external partner

Books of Record

Business Need: Create an Enterprise Data Warehouse on the Netezza platform to support the creation of Clinical, Claims, Member, Provider and Product sources for internal reporting as well as external consumption

Business Need: Create a reporting datamart to support strategic reporting

Member Matching

Business Need: Provide a higher granularity for matching members identifiable with varying health care consumer keys from disparate data sources.

Refined direct/deterministic looks and mastered probabilistic (MDM- related) attributes


Business Need: Implement pharmacy and medical benefits authorization for MedHOK

Integrates with claims adjudication and back-end processes such as case management, appeals and post-service claim review

Enables efficient authorization determinations

Improved operational efficiency and effectiveness, return on investment, member and provider experiences, member health and overall quality by focusing our resources towards higher return activities, automating the lower return activities and redesigning processes.