AI-Powered Healthcare Payer Solutions & Services

Overview

Healthcare payers are under persistent pressure to keep up with the unprecedented digital adoption rates, administrative costs, complex regulatory guidelines and rising customer expectations. With global claims denial and rejection rates running high, payers need more than just point solutions that fail to deliver measurable outcomes.More

Healthcare payers are under persistent pressure to keep up with the unprecedented digital adoption rates, administrative costs, complex regulatory guidelines and rising customer expectations. With global claims denial and rejection rates running high, payers need more than just point solutions that fail to deliver measurable outcomes. Tech Mahindra leverages artificial intelligence (AI), intelligent automation and advanced analytics to re-design payer processes giving them a new digital-first scalable foundation.

Our solutions have a strong focus on data privacy, security, regulatory compliance, and fraud management to ensure member experiences are faster, better and safer.

Less

0 K+
Consultants
1.50 Mn
Enrollment Calls Handled
0
Out of Top 10 payer as Clients

End-to-End Services for Payers

GenAI-powered member management solutions with unified member enrollment, premium billing, and revenue reconciliation processes powered by real-time member data for patient-centric value-driven outcomes.

  • Group Enrolment / Set-up
  • Individual Enrolment
  • Premium Billing
  • Benefits Configuration / Set-up
  • Member AEP Customer Service Support
  • Welcome Pack Distribution

AI-driven provider lifecycle management that helps healthcare payers and providers with accurate, compliant, and automated provider data operations.

  • Provider Recruitment and Credentialing
  • Contracting and Negotiation
  • Network Adequacy Oversight
  • Provider Data Management
  • Value-Based Program Design
  • Provider Training & Commissioning

AI‑powered workflows that accelerate authorizations and claims processing, improve operational efficiency, and support proactive gap closure to help improve Star Ratings.

  • Claims Processing & Adjudication
  • Appeals & Grievances
  • COB Management
  • Claims Adjustments
  • Member Services
  • Provider Services
  • Claims FWA Audit
  • Risk Adjustments & Coding
  • HEDIS, Star rating management

Cloud‑first, unified data foundations and case management and disease management workflows to strengthen value‑based care performance and patient outcomes.

  • Care Management
  • Case Management
  • Utilization Management
  • Population Health & SDOH Integration
  • Telehealth & Digital Care Navigation
  • Discharge Planning & Coordination
  • Member Outreach

AI-powered transformation levers that help reduce administrative burden, improve compliance, accelerate return-to-work (RTW), and lower medical and operational costs.

  • Medical Bill Review
  • Utilization Review
  • Medical Document Summarization
  • Care Management
  • Document Management

Help patients avoid unnecessary hospitalizations and reduce costs through personalized home-based care, supported by seamless coordination, patient-friendly processes, and care navigation services.

  • Patient Scheduling and Coordination
  • Contact Center Services
  • Clinical Support Services
  • Document Management and Data Entry

AI and Automation Accelerators

Utilization Review

Real-time integration with payer rules and clinical guidelines with AI-based analysis of medical necessity and coverage criteria.

AI-Powered Claims Scrubber

AI-powered review for the claims process and documentation to instantly correct them and prevent denials.

Medical Document Summarization

Automatic condensation of documents into clear, actionable summary for quick extraction of key insights.

Fraud Detection

Self-learning AI to detect existing and emerging fraud cases with real-time claims analysis and outlier flagging.

Integrated Care Delivery Model

AI-driven integrated workflows connecting risk adjustment, quality management, care coordination, member engagement, documentation, and financial optimization.

Key Highlights

Industry Leadership

25+ years of healthcare leadership experience.

AI-Augmentation

AI-augmented operations with custom solutions for each process across the payer value chain.

Operational Scalability

We offer scalability across regions including the US, LATAM, Africa, India, and the Philippines.

Domain Specialization

Experience across Medicare, Medicaid, Commercial, and ACA business.

Pricing Models

Our pricing model ranges from fixed-price to FTE-based and outcome-based models.

Business Impact

  • 98%+ clean claim rate
  • 33% improvement in RAF accuracy
  • 20% Increase in member CSAT
  • Up to 99% coding accuracy in HCC coding delivered
  • $1M to $2M as annual savings through reduced overutilization of services
  • $400 to $700K savings through improved compliance and audit readiness
  • $1.5M+ identified exposure for a single provider billing an average of 44 hours of services/day

Explore More

Digital Transformation in Healthcare and Life Sciences

Navixus™ Consulting CoE

Geographic Information System (GIS)

Get In Touch

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