Risk Adjustment and Quality Performance Solutions
Improve revenue integrity, compliance readiness, and quality performance while building a more complete picture of member health.
Solving the complexity of risk adjustment and quality performance
Health plans face increasing pressure to maintain coding accuracy, protect revenue, strengthen compliance, and improve quality performance while keeping pace with evolving CMS requirements. Disconnected coding, quality, and outreach programs can create inefficiencies, unaddressed care gaps, and incomplete documentation.
Carelon combines scalable risk adjustment operations with intelligent workflow enablement to help health plans improve coding accuracy, strengthen audit readiness, and connect risk adjustment and quality programs through a more coordinated operating model.
A smarter approach to risk adjustment and quality performance
Capture a more complete picture of member health
Improve coding accuracy and revenue integrity through scalable operations, certified coding expertise, and intelligent workflow support.
- Hierarchical Condition Category (HCC) coding support designed to align with applicable requirements across all lines of business
- Coding workflows that support accurate risk adjustment factor (RAF) score capture and support appropriate reimbursement
- Scalable operations that reduce administrative strain, improve risk accuracy, and give your teams more time to focus on clinical and strategic priorities
Strengthen compliance and quality performance
Improve audit readiness and quality outcomes through integrated coding validation, quality assurance, and documentation review.
- Automated coding and clinical evidence reviews
- Intelligent text recognition helps interpret handwritten notes and medical abbreviations, reducing manual review time
- Audit scoring and auto-generated compliance reporting that help reduce audit and repayment risk
Drive continuous operational improvement
Strengthen long-term performance through programs powered by experienced teams, actionable insights, and workflows designed for continuous improvement.
- Flexible delivery models with coders trained across programs and tools
- Real-time dashboards and configurable quality assurance workflows
- Gap analytics and coding overread for process optimization
Solutions for better risk and quality operations
Risk adjustment coding and review
Support accurate coding and documentation through scalable retrospective and concurrent coding operations.
Quality performance and care gap programs
Advance quality initiatives through targeted outreach and integrated operational support.
Coding audit and compliance management
Strengthen audit readiness and operational consistency through coding validation and quality assurance workflows.
Analytics and workflow optimization
Improve operational performance through analytics, automation, and continuous workflow improvements.
Proven performance across risk adjustment and quality operations
Our coding expertise and scalable operations help health plans achieve smarter risk adjustment and quality transformation.1
Results reflect select programs and may vary by client, workflow, and scope.
Ready to optimize risk adjustment and quality performance?
Transform risk adjustment and quality operations with scalable solutions that help improve coding accuracy, strengthen compliance, and support revenue integrity.
1 Internal data, 2024.