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EXLCLARITY is a software designed to support data management, analytics, and business intelligence capabilities for organizations seeking to optimize decision-making and improve operational efficiency. The software enables data integration from various systems, providing data quality management and governance tools to ensure data consistency and reliability. It includes features for data visualization, advanced analytics, and reporting to help organizations identify trends, reduce manual processing, and address compliance requirements. By centralizing and standardizing data operations, the software helps organizations overcome challenges related to fragmented data sources and streamlines access to actionable insights for business users.
Innovaccer Data Activation Platform is a software designed to unify healthcare data from disparate sources to enable analytics-driven decision-making. The software integrates electronic health records, claims, and other healthcare data to create a standardized, longitudinal patient view, supporting care management, population health initiatives, and performance improvement. It provides tools for data normalization, enrichment, and governance, along with capabilities for reporting, predictive analytics, and workflow automation. The software aims to address challenges related to data silos, fragmented patient information, and inefficient care coordination by facilitating data accessibility and actionable insights within healthcare organizations.
IQVIA NLP Platform is a software designed to extract, process, and analyze unstructured clinical and biomedical data using natural language processing techniques. The software transforms information from sources such as medical records, clinical notes, and various documents into structured data suitable for research, analytics, and decision support. It enables the identification of key patterns and trends by converting text data into actionable insights and supports tasks such as cohort identification, data abstraction, and real world evidence generation. The software addresses challenges related to the handling and interpretation of large volumes of complex healthcare data, streamlining workflows in life sciences and healthcare organizations.
TriZetto Risk Score Manager is a software designed to assist healthcare organizations in managing and optimizing risk scores for member populations. The software supports workflows for calculating, validating, and reporting risk adjustments, which are critical for accurate reimbursement and regulatory compliance in risk-based healthcare programs. It enables users to automate data collection, streamline analytics, and improve the management of risk adjustment initiatives. The software helps organizations identify coding gaps, assess financial impacts, and ensure that risk scores reflect the complexity of member health statuses. This supports operational efficiency and more precise financial forecasting in healthcare environments.
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Features of U.S. Healthcare Risk Adjustment Solutions
Updated August 2025
Mandatory Features:
Workflow management to maintain risk adjustment cases and in-home assessments
Generating state-specific and other required file types, such as X12 837 and 834 electronic data interchange (EDI) transactions, for the electronic submission of eligibility and encounter data
HCC coding to submit risk-adjusted factors for member populations
EDS capabilities that allow a health plan to submit monthly regulatory documentation
Risk-scoring algorithms or analytics to stratify member populations
Reporting and analytics to forecast member health and associated cost of care
What are U.S. Healthcare Risk Adjustment Solutions?
Gartner defines U.S. healthcare payer risk adjustment solutions as tools, often augmented by AI and machine learning (ML), to appropriately gauge the health of members and optimize health-risk-related revenue. Payers use these tools across business lines, including Medicare Advantage, Affordable Care Act (ACA) individual and small employer, managed Medicaid, and, increasingly, commercial group coverage under value-based purchasing arrangements. Coding, risk adjustment optimization, care gap analysis and encounter submissions are key capabilities. Risk adjustment solutions can be purchased as services or software offerings.
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