This project documents the product ownership of a net-new care management integration at a nonprofit health plan in Minnesota — connecting OB providers to the health plan's GuidingCare care management platform through a structured pregnancy risk assessment workflow. Providers accessed the assessment screen via a link in the provider portal, completed the prenatal risk assessment in a vendor-built form, and that data flowed directly into GuidingCare — enabling the health plan to identify high-risk pregnancies and trigger care coordinator outreach for the first time through a structured digital channel.
Role: Senior Business Analyst / Product Owner (scope, integration design, UAT) Regulatory Driver: HEDIS Prenatal/Postpartum Care Measures + CMS Medicaid Care Management Requirements Integration Type: Provider portal → Vendor assessment screen → GuidingCare Population Served: Medicaid pregnant members
The health plan had no structured digital channel for OB providers to submit pregnancy-related clinical data into the payer's care management system. Prenatal risk assessments, lab results, and postpartum follow-up information existed in provider workflows — but never made it to the payer in a timely, structured, or actionable format.
This created three compounding problems:
1. HEDIS measure gaps Prenatal and postpartum HEDIS measures require documented evidence of timely care — risk assessments completed, postpartum visits confirmed. Without a structured data submission path, care coordination staff had to chase providers manually, and measure performance suffered.
2. CMS Medicaid care management compliance risk CMS Medicaid requirements mandate proactive care management for high-risk pregnant members. Without clinical data flowing from providers, the health plan could not identify high-risk pregnancies early enough to intervene effectively.
3. No baseline capability to build on This was not a system replacement or upgrade. There was no prior integration, no prior workflow, and no prior data structure for pregnancy care management data at the payer level. Everything had to be designed from scratch.
A multi-vendor integration linking the provider portal, a vendor-built pregnancy risk assessment screen, and GuidingCare — enabling structured provider data submission across the full pregnancy care continuum.
- Provider logs into the provider portal
- A link in the portal directs them to the pregnancy risk assessment screen — built by a separate vendor
- Provider completes the structured assessment form (prenatal risk data, lab values, clinical findings)
- Submitted data flows into GuidingCare, triggering care coordinator workflows for high-risk members
| Feature | Description |
|---|---|
| Prenatal Risk Assessment Screen | Vendor-built structured form capturing risk stratification data at first prenatal visit |
| Provider Portal Link | Seamless entry point from provider portal to assessment screen — no separate login required |
| Lab / Clinical Data Capture | Structured ingestion of key prenatal lab values and clinical findings into GuidingCare |
| Care Coordinator Outreach Triggers | Submitted data triggers outreach workflows for high-risk members in GuidingCare |
| Postpartum Follow-up | Provider submission of postpartum visit confirmation, closing the HEDIS measure loop |
As Product Owner and Senior Business Analyst, I owned the scope definition, integration design, and UAT for this initiative — coordinating across two vendors and multiple internal stakeholders with no prior system to reference.
What I did:
- Defined product requirements and data submission specifications from scratch, working directly with clinical, compliance, IT, and both vendor teams
- Designed the end-to-end workflow — from provider portal entry point through assessment form submission to GuidingCare data ingestion
- Coordinated integration requirements between the provider portal vendor and the assessment screen vendor to ensure seamless handoff
- Translated HEDIS measure technical specifications and CMS Medicaid care management requirements into functional requirements for the assessment form fields
- Led UAT, including workflow testing, data accuracy validation, and HEDIS measure closure verification
- Coordinated provider-side communication to drive adoption of the new submission workflow at go-live
flowchart TD
A[OB Provider\nlogs into Provider Portal] -->|Clicks pregnancy\nassessment link| B[Pregnancy Risk Assessment Screen\nVendor-built form]
B -->|Provider completes\nstructured assessment| C[Form Submission]
C --> D[GuidingCare Platform\nPayer]
D --> E[Prenatal Risk Data\n→ Member Care Record]
D --> F[High-Risk Flag\n→ Care Coordinator Outreach]
D --> G[Postpartum Confirmation\n→ HEDIS Measure Closure]
Key design decisions:
- Provider portal as entry point — leveraging the existing provider portal reduced friction and avoided requiring providers to access a separate system directly
- Separate vendor for assessment screen — the structured form was purpose-built by a specialist vendor, keeping GuidingCare as the system of record without requiring custom development on the core platform
- Structured field mapping — each form field mapped to HEDIS measure technical specifications to ensure measure-ready data at point of capture
- Validation at submission — form validation rules enforced before data entered GuidingCare, reducing downstream care coordinator rework
HEDIS Prenatal / Postpartum Care Measures
- Prenatal Care (PPC): Timeliness of first prenatal visit and risk assessment documentation
- Postpartum Care (PPC): Postpartum visit completion within required timeframe
- Provider-submitted data via this workflow closes measure gaps that previously required manual outreach to confirm
CMS Medicaid Care Management Requirements
- CMS requires health plans to identify and manage high-risk pregnant Medicaid members proactively
- Provider-submitted risk assessment data enables earlier identification of high-risk pregnancies, triggering timely care coordinator intervention
- Delivered a net-new provider-to-payer data submission workflow with no prior system or baseline to reference — designed from requirements through deployment
- Enabled structured clinical data submission from OB providers into GuidingCare for the first time at the health plan
- Created a direct data pipeline supporting HEDIS prenatal and postpartum measure closure, reducing reliance on manual provider outreach
- Coordinated a multi-vendor integration (provider portal vendor + assessment screen vendor + GuidingCare) with no prior template for how these systems should connect
Coordinating across two vendors with different technical stacks and delivery timelines — while keeping GuidingCare integration requirements stable — was the core operational challenge of this project. The provider portal vendor and the assessment screen vendor had no prior working relationship, and the integration spec between them had to be defined and owned by the product team.
The lesson: when you're the only party who sees the full picture, you become the integration layer. Clinical requirements, HEDIS specifications, vendor technical constraints, and provider usability all had to be synthesized into a single coherent workflow — and that synthesis was the product work, not just the documentation of it.
Note: All artifacts are sanitized to remove PHI and proprietary system details in compliance with HIPAA.
- Integration requirements document — sanitized
- Assessment form field mapping (HEDIS-aligned)
- UAT test plan — workflow & HEDIS measure closure scenarios
- HEDIS measure technical specification mapping
This repository documents product ownership work completed at a nonprofit Medicare and Medicaid health plan. All data, member records, and system details have been sanitized or synthesized for public sharing.