​Sheela for Managed Care Organizations
Optimize care delivery, utilization management, and member engagement for higher compliance
Whether you're an HMO, PPO, IPA, or integrated delivery system, Sheela helps you achieve your dual mandate of improving health outcomes and managing costs.
​Managed Care Organizations balance quality care delivery with cost management across complex provider networks. Sheela enables MCOs to automate utilization management, coordinate care transitions, engage members proactively, and ensure providers follow care protocols - all while reducing administrative costs.
Key Use Cases for MCOs
Prior Authorization Support
Automated PA status updates, expedite urgent requests, and streamline provider communication
Utilization Management
Track high utilizers, identify unnecessary ER visits, and coordinate appropriate care settings
Care Transitions
Post-discharge follow-up, transition to lower levels of care, and readmission prevention
Case Management Support
Regular member check-ins, care plan adherence monitoring, and barrier identification
Pharmacy Management
Medication adherence programs, formulary compliance, and therapeutic alternatives
Nurse Advice Line
24/7 first-line triage before escalation to clinical staff, reducing after-hours costs
Population Health Outreach
Preventive care campaigns, chronic disease management, and risk stratification support
Provider Network Management
Steerage to preferred providers, network adequacy support, and provider satisfaction
Benefits & Eligibility
Real-time benefit verification, member services, and plan navigation assistance
Benefits
Reduce Medical Loss Ratio
Prevent unnecessary utilization and complications through proactive member engagement
Lower Administrative Costs
Automate routine member and provider inquiries, reducing call center expenses by 40-60%
Improve HEDIS & Stars Ratings
Systematic outreach for quality measures drives better performance on key metrics
Enhance Member Satisfaction
24/7 availability and immediate response improve member experience and retention
Scale Care Management
Extend care management reach without proportional increases in nursing staff
Provider Satisfaction
Reduce provider abrasion with faster PA decisions and better communication
Utilization Management Automation
Sheela can be used to manage prior auth workflow and UM life-cycle for improved service levels,
reduced cost of operations and more importantly avoiding audit risks when compared with manual
decision-making process between staff
Prior Authorization Workflow
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Status Inquiries - Instant PA status for providers and members without human involvement
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Requirements Communication - Automated notification of missing clinical information
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Urgent Expedites - Fast-track urgent cases and immediately notify providers of decisions
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Appeal Support - Guide providers through appeal process and gather required documentation
Utilization Monitoring
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High Utilizer Identification - Proactive outreach to frequent ER and hospital users
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Appropriate Care Setting - Educate members on when to use PCP, urgent care, or ER
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SNF & LTAC Transitions - Monitor extended stays and coordinate step-down to lower levels
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Home Health Utilization - Ensure appropriate home health services and prevent overutilization
Care Coordination Features
Hospital Discharge Planning
Coordinate post-acute services, ensure medication availability, schedule follow-up appointments
Care Plan Adherence
Regular check-ins for complex cases, monitor progress, identify and address barriers
PCP Assignment
Help new members select PCPs, explain medical home model, schedule initial visits
Social Determinants
Screen for SDOH needs, connect to community resources, coordinate transportation
Specialist Coordination
Ensure PCP referrals are obtained, schedule specialist visits, facilitate communication
Behavioral Health Integration
Coordinate physical and behavioral health care, reduce fragmentation
Quality & Performance Management
HEDIS Measure Support
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Preventive Care - Breast cancer screening, colorectal cancer screening, cervical cancer screening
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Diabetes Care - A1C testing, eye exams, kidney function monitoring, blood pressure control
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Cardiovascular - Cholesterol management, statin therapy adherence, blood pressure control
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Behavioral Health - Depression screening and follow-up, substance abuse treatment
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Medication Management - Adherence for diabetes, hypertension, cholesterol medications
Medicare Stars Measures
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Member Experience (CAHPS) - Improve satisfaction scores through better communication
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Care Coordination - Post-discharge follow-up, medication reconciliation
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Plan Responsiveness - Fast access to services, 24/7 availability
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Medication Safety - High-risk medication monitoring, drug-drug interactions
Provider Network Engagement
Provider Hotline
Dedicated line for provider offices with instant PA status, eligibility verification, and claims inquiries
Quality Feedback
Share quality performance data with providers, identify improvement opportunities
Practice Support
Help practices close care gaps, provide patient lists, offer workflow assistance
Value-Based Care
Support providers in value-based contracts with member engagement and data sharing
Integration with MCO Systems
Sheela integrates seamlessly with your managed care technology stack
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Core Administration Platforms - Real-time eligibility, benefits, enrollment data
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Utilization Management Systems - PA status, case management, concurrent review
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Claims Systems - Claims status, payment information, provider remittance
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Care Management Platforms - Risk stratification, care plans, intervention tracking
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Provider Portals - Two-way integration for seamless provider experience
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Pharmacy Benefit Managers - Formulary information, medication history, adherence data
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HIE/ADT Feeds - Real-time admission, discharge, transfer notifications
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Analytics Platforms - Feed interaction data for reporting and insights
MCO-Specific Compliance
NCQA Accreditation
Support NCQA standards for care management, utilization management, and member rights
State Regulations
Configurable to meet varying state MCO requirements and Medicaid managed
care rules
CMS Requirements
Comply with Medicare Advantage and Medicaid managed care program requirements
Grievance & Appeals
Proper intake and documentation of member grievances and appeal requests
Continuity of Care
Ensure new members can continue with current providers during transition periods
Timely Access Standards
Help meet state and federal requirements for appointment availability
