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Payer Clinical Operations

Better Outcomes, Lower Cost.

Dedicated teams of experts to efficiently scale your clinical operation needs and sustain your inevitable growth

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Quality-Focused Services to Scale Your Clinical Teams

Shearwater Health provides expert resources across multiple clinical domains

Utilization Management

Ensuring quality, repeatability, and sustainability.

Utilization Management

  • Intake & Patient Registration
  • Network Coordination
  • Clinical Medical Necessity Review
  • Concurrent, prospective, retrospective
  • Post-Decision Support
  • Appeals & Grievances
  • Quality of Care Audit
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    Risk Adjustment

    Expertise in underlying health status and health spending.

    Risk Adjustment

  • Chart Retrieval
  • Chart Abstraction/Coding
  • Prospective, Concurrent, Retrospective

    • HEDIS Review

    Ensuring quality and effectiveness of care delivered to patient populations.

    HEDIS Review

  • Chart Abstraction
  • Chart Retrieval
  • Supplemental Data Audit
  • STARS Outreach Campaigns
  • MRRV Audit
  • Quality of Care

    • Member Engagement

    Focus on patient-centered care and communications.

    Member Engagement

  • Outbound Member / Patient Engagement
  • Care Coordination
  • Health Coaching
  • Care Management
  • Remote Patient Monitoring
  • Social Determinants of Health
  • Health Risk Assessment Outreach

    • DME & HIT Claim Management

    Navigating through benefit claims.

    DME & HIT Claim Management

  • Medical Record Review
  • Medical Necessity Review
  • Medical Summary

    • Recovery Audit Contractor (RAC) Services

    Detecting & correcting past improper payments to prevent recurrence.

    Recovery Audit Contractor (RAC) Services

  • Readmission Prevention
  • Clinical Review
  • RAC Audit Admin Support

    • Claims & Benefits Management

    Managing Medical Claims-Billing while maintaining timeframe standards.

    Claims & Benefits Management

  • Medical Record Review
  • Claims Documentation (claim, billed charges, benefit coverage)
  • • Claims Denials Prep
  • Claims Adjudication Prep
  • Post Service Appeals Prep
  • Investigation of Billing Issues
  • Management of Medical Services
  • Claims-billed Charge Review
  • Benefit Administration

    • Value-based Care

    Driving success of value-based care & bundled payments programs.

    Value-based Care

  • Bundled Payment Episodic Clinical Reviews

    • Home Health Care

    Optimizing home health care processes.

    Home Health Care

  • Intake
  • Oasis Management
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    Poor Quality is Costly. At Shearwater Health, Quality is Our Top Priority.

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    Nurse Retention Rate

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    Quality & Productivity SLA Adherence

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    Average Direct Labor Savings

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    Charts / Cases Annually Reviewed

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    Calls to Patients / Providers Annually

    We Understand the Current Landscape

    Increasing complexity of reimbursement

    Growing prevalence of clinical review and documentation must be performed by appropriately trained, qualified resources.

    Market and regulatory dynamics

    Increasing the burden of clinical expertise required across healthcare vertical and core business functions.

    Clinical shortages impact quality of care

    Costly and labor-intensive to hire and retain skilled clinicians, creating challenges with scaling.

    Partner with us to Deliver Quality Outcomes at Scale

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    People
    • Nurse retention rates exceed 80%
    • Average management tenure is 6 years
    • Average team leader tenure is 4 years
    • Subject matter experts in operational management
    Process
    • Operate 3 HITRUST, URAC HUM accredited centers
    • Six Sigma strategy embedded into service delivery model
    • Rapid scaling of dedicated clinical resources
    • 24/7 efficient coverage and higher throughput
    Results
    • Reduce rework loop by 10% on average
    • 97% decision accuracy in UM
    • 99% quality rating for medical record reviews in HEDIS
    • 98% quality & productivity SLA adherence

    Our Accreditations & Certifications

    Health Utilization Management Certification
    08/01/2027
    r2 HITRUST Certified badge
    Alliance for Ethical International Recruitment Practices graphic
    Workers' Compensation Utilization Management
    04/01/2027

    Still Unsure? See Us In Action!

    Review our real-life examples of custom solutions we have created for payers just like you.

    Contact Us

    20 Burton Hills Blvd., Suite 400,
    Nashville, TN 37215

    615.921.9510

    info@swhealth.com

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