Risk-Bearing Organizations
Delegated Risk Management for Risk-Bearing Organizations
Manage More Delegated Lives. Not More Administrative Overhead.
Whether you assume medical risk or manage operations for risk-bearing groups, growing delegated populations bring more authorizations, clinical reviews, care coordination and reporting.
ZeOmega brings established health plan technology and intelligent automation to help streamline those workflows and control total operating costs.
#1 Best in KLAS, Payer Care Management Solutions, 2022–2025
25 years in healthcare management
Established experience serving health plans and complex care organizations
Payer-Like Responsibilities. Without Payer-Level Complexity.
Across Medicare Advantage, Medicaid managed care, and commercial risk arrangements, MSOs, IPAs, medical groups, ACOs, and other risk-bearing organizations are assuming greater financial, clinical, and administrative responsibilities. While some organizations assume medical risk directly, others manage delegated functions on behalf of those that do.This shift creates significant opportunity but also introduces operational complexity. Multiple payer requirements, increasing authorization volumes, manual workflows, care coordination demands, regulatory deadlines, and delegation oversight can drive administrative costs higher as membership and responsibilities expand.
Organizations are increasingly managing payer-like responsibilities without the operational infrastructure needed to scale efficiently.
ZeOmega helps close that gap by unifying clinical and administrative workflows, automating utilization and care management processes, and improving visibility across delegated operations—enabling organizations to scale efficiently, reduce the total cost of operations, and better manage performance under risk-based contracts.
Organizations are increasingly managing payer-like responsibilities without the operational infrastructure needed to scale efficiently.
ZeOmega helps close that gap by unifying clinical and administrative workflows, automating utilization and care management processes, and improving visibility across delegated operations—enabling organizations to scale efficiently, reduce the total cost of operations, and better manage performance under risk-based contracts.
The payer-like work that comes with delegated risk
More delegated lives should not mean proportionally more administrative staff. These six operational pressures can erode margins and strain clinical teams.
Prior authorization at scale
Electronic submission is only the first step. As volumes and payer rules grow, organizations also need to automate intake, policy routing and eligible clinical determinations while directing complex cases to reviewers.
Delegated utilization management
Clinical reviews must be consistent, documented and aligned to delegated requirements, while supporting timely decisions and oversight.
Care management for complex populations
For complex and high-risk populations, coordinated assessments, care plans, transitions and follow-up can connect utilization decisions to ongoing care. Emerging episode-based and value-based arrangements make this coordination increasingly important.
Multi-payer clinical policy management
Different payer contracts may require different criteria, rules and reporting. Teams need clear workflows for applying the appropriate policy.
Delegation oversight and audit readiness
Delegated organizations need accessible records, defensible decisions and reporting to support health plan oversight and audits.
Data exchange and interoperability
Eligibility, authorizations, clinical information and reporting need reliable exchange. Applicable CMS-0057-F obligations depend on the payer and delegation arrangement; confirm requirements with compliance.
Proven Clinical Operations Technology. Built for Complex Delegated Work.
ZeOmega brings established experience supporting health plans with utilization management, care management and clinical operations. For MSOs and risk-bearing organizations, the opportunity is to streamline fragmented workflows, improve staff productivity and support growth without matching it with administrative headcount.
Electronic prior authorization helps move requests and information between providers and payers; intelligent clinical automation can help reduce the manual work of reviewing them. Jiva and the Smart UM Suite can support connected clinical operations. Confirm specific interoperability, automation and auto-approval capabilities with Product before publication.
Smart UM Suite
Go beyond electronic submission with policy-driven workflows, AI-assisted clinical review and automated approvals for eligible requests. Route complex cases to clinicians; confirm supported automation scenarios with Product.
Utilization management
Support configurable review workflows, including concurrent, medical director and behavioral health UM; confirm licensed modules and rules.
Electronic prior authorization
Streamline provider-to-payer authorization transactions through FHIR-enabled interoperability, helping reduce manual intake, data entry and administrative friction. Confirm available APIs and compliance scope with Product.
Care management
Coordinate outreach, assessments, individualized care plans, transitions and follow-up for high-risk and complex populations, including those in value-based or episode-based arrangements.
Population health management
Use available data and analytics to prioritize populations and identify opportunities for intervention.
Clinical criteria
Support clinical criteria workflows; MCG and InterQual integrations are optional and subject to licensing and configuration.
Provider self-service
Enable provider-facing authorization workflows; confirm portal functionality and availability for the proposed configuration.
Delegated clinical services
Explore complementary clinical services where offered and appropriate; validate scope before publication.
Built for Organizations Managing Delegated Risk and Operations
Management services organizations (MSOs)
Standardize UM, authorization and care coordination workflows across multiple affiliated organizations and payer contracts.
Independent physician associations (IPAs)
Support delegation oversight, policy consistency and clinical workflows as payer relationships expand.
Medical groups
Coordinate risk-bearing clinical operations and care management across covered populations.
Accountable care organizations (ACOs)
Connect care coordination, utilization insights and population-focused workflows in value-based arrangements.
Provider-sponsored organizations and other delegated entities
Support complex delegated operations and coordination across providers, payers and affiliated entities.
Where Is Delegated Risk Driving Your Operating Costs?
Start with a focused conversation about your delegated UM, authorization, care management and administrative workflows. We can explore opportunities to reduce operating costs and determine whether a scoped pilot or assessment is appropriate; scope and deliverables would be agreed separately.
What we assess
- Prior authorization
- Utilization management
- Care management
- Clinical policy
- Compliance and audits
- Data exchange
Potential discussion outcomes
A shared view of your highest-friction workflows
Potential opportunities to reduce manual work and operating costs
Recommended next steps for deeper evaluation, if appropriate
A follow-up discussion with relevant ZeOmega specialists