Member 360: Health Plans & Managed Care

For health insurers and managed care organizations, inaccurate member identity is a huge operational and regulatory liability. Duplicate member records generate incorrect claims adjudication. Unresolved member identities across plan years, employer groups, and lines of business create gaps in risk adjustment data that directly affect CMS reimbursement. Care management programs reach the wrong members – or miss eligible ones entirely – because the member record is fragmented across enrollment systems, claims platforms, pharmacy data, and third-party sources.

What inaccurate member identity costs a health plan

The financial exposure is direct and measurable. RAF scores built on incomplete member-to-claim relationships understate risk and reduce CMS reimbursement. HEDIS measure attribution breaks when member identity is not resolved across plan years. Care management programs that target the wrong population waste program spend and miss the members who need intervention most.

Rysun's Member 360 accelerator on AWS resolves member identity across heterogeneous source systems, establishes a HIPAA-compliant Golden Record, and enables the population health, risk adjustment, and care management programs that depend on knowing who your members actually are.

A longitudinal member identity across plan years

A member record your population health, risk adjustment, and care management programs can actually build on – resolved across sources and linked across plan year transitions and life events.

• Member identity resolved across enrollment, claims, pharmacy, and third-party sources
• A longitudinal record linking identity across plan year transitions and life events
• Risk stratification and RAF scoring inputs built on the governed member master
• Stewardship workflows surfacing duplicate resolution queues and data quality alerts

Delivered in phases over 12–20 weeks. HIPAA compliance requirements, source system scope, CMS reporting obligations, and state regulatory considerations confirmed at engagement start. Larger programs finalized via private offer.

Recommended AWS stack

AWS HealthLake for FHIR-structured member data and HIPAA-eligible controls, Amazon OpenSearch Service for deterministic and probabilistic member matching, Amazon SageMaker AI for risk stratification and RAF scoring inputs, Amazon Comprehend Medical for clinical context extraction from unstructured data, Amazon Bedrock for stewardship assist, Amazon QuickSight for compliance and population health dashboards.