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Case Study
Health Plan
A regional health plan serving 1.2 million members across four states operated with fragmented member data distributed across a legacy claims adjudication system, a separate eligibility platform, a third-party care management application, and Salesforce Service Cloud for member services. No single system provided a complete view of a member.
Member services representatives required an average of four application switches per call to answer basic member inquiries. Care management teams maintained parallel records in their application and in spreadsheets. Marketing had no reliable way to segment members for health education campaigns because engagement data lived in yet another system.
The health plan needed a unified member view that consolidated data from all sources, was accessible within the Salesforce environment their teams already used, and could ingest clinical data from their provider network via FHIR R4 APIs to support the health plan's expanding value-based care programs.
Selah Digital designed the solution around Salesforce Data Cloud as the unification layer, with Health Cloud as the presentation layer for member-facing teams. This architecture allowed the health plan to ingest and harmonize data from all source systems without requiring those systems to change their data formats or APIs.
The integration architecture comprised four data streams: claims and eligibility data from the legacy systems via nightly batch ingestion, care management data via real-time API integration, provider clinical data via FHIR R4 Bulk Data Access operations from participating provider EHRs, and engagement data from the health plan's member portal and marketing platforms.
Data Cloud identity resolution was configured to match member records across systems using a multi-attribute matching algorithm that accounted for name variations, address changes, and the multiple member IDs generated by different systems. The resolution rules were developed in collaboration with the health plan's data governance team and tested against a curated set of known member records with cross-system linkages.
The Member 360 view in Health Cloud surfaced the unified member profile to care management, member services, and population health teams. Each team received a purpose-built page layout that presented the data relevant to their workflows, drawing from the same unified Data Cloud profile.
The Member 360 deployment unified data from seven source systems into a single member profile. Identity resolution achieved a 97.3% match rate across the member population, with a false positive rate below 0.4%. The remaining unmatched records were flagged for manual review by the data governance team.
Member services call handling time decreased by 34%, from an average of 8.2 minutes to 5.4 minutes, driven primarily by eliminating application switching. First-call resolution improved from 67% to 84% because representatives had access to claims, eligibility, and care management context in a single view.
The FHIR R4 integration with the provider network ingested clinical data from 340 provider organizations within the first three months. This clinical data enriched the member profile with recent encounter history, active diagnoses, and medication lists, enabling the care management team to conduct more informed outreach for members in value-based care programs.
A 12-hospital health system deployed Health Cloud for care coordination with the same senior team from discovery through go-live.
A federal health agency deployed AI-assisted clinical documentation within a FedRAMP Authorized environment, meeting compliance requirements while reducing documentation burden.
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