What is Medicaid Management?


Fast and accurate claims processing. Managed care oversight. Continued compliance in the face of shifting rules and regulations. Increased enrollment and tightening budgets.

It’s a lot for anyone to stay on top of.

Medicaid is complex, and it's constantly changing. We’ve been helping agencies like yours wrangle it for five decades.

Our CMS-certified Medicaid Management solutions are modular, intelligent and cloud-based, and they cover all your management needs. Claims and encounters? Check. Provider Solutions? Check. Managed care, EDI clearinghouse, prior authorization, value-based care? Check, check, check and check. And much, much more, but you get the idea.

Don’t need all that? No problem. You can take the whole bundle or just the modules you need. We’ll set things up exactly the way you want.

Why Medicaid Management?

Intelligent solutions for you

Save time, money, headaches

All-in-one or à la carte

How we can help.

Our people have deep knowledge, and our systems are smart and evolved. We can help to accelerate claims processing, support value-based care and control escalating costs with our comprehensive and integrated suite of solutions that orchestrates workflow and task management.

Core Medicaid Solutions

Claims, Encounters and Financials

Keeping your claims, encounters and financials straight in the face of shifting healthcare needs, ever-increasing enrollment and federal policy changes is exhausting. We provide enterprise-wide COTS modularity to support state-specific Medicaid needs and other health and human services programs. Accurately process claims and encounters and enable rapid roll-out of policy changes. Enjoy high-grade security, integrity and output to diverse trading partners and providers while meeting federal requirements.

EDI Clearinghouse

Our EDI Clearinghouse solution simplifies provider Medicaid billing with comprehensive validation rules for managed care and fee-for-service transactions and provides a single point of submission, ensuring encounter data is compliant.

Provider Service

Wrangling providers is a time-consuming endeavor that can be full of inefficient and repetitive manual processes. We can ease your burden.

Provider Service tools is a flexible, cloud-based SaaS platform based on COTS software. It’s aligned with industry standards to assist providers from initial enrollment through final determination letter and supports providers’ participation in fee-for-service and other programs, including enrollment with MCOs.

Managed Care

Our Managed Care solution enables state agencies to be more proactive in easily managing multiple MCOs, with cost containment and quality as the drivers. Tracking member MCO enrollment as they transition across different plans, and improving capitation payment forecasting and payment processing allows our clients seamless end to end administration of their Managed Care Program.

Prior Authorization

With Gainwell’s Prior Authorization solution, we enable state Medicaid agencies to automate authorizations with configurable rules and workflows to improve member and provider satisfaction from efficient, expedited authorizations.

Provider Solutions

Provider Credentialing

At Gainwell, we have deep expertise ensuring state Medicaid programs are equipped with advanced provider solutions. Our Provider Credentialing solution delivers reduced provider abrasion, increased control and oversight of the credentialing process, and improved cost-savings ensuring a simplified credentialing and re-credentialing process.

Value-Based Care

With our decades of experience in the Medicaid industry managing claims data and provider payments, coupled with innovative solutions for value-based care analytics, consultation and administration, Gainwell is uniquely positioned to support improving quality, reducing cost and improving the patient care experience and outcomes for our clients’ populations.

We can help. But the next move is yours!

Please fill out the information below to start a no-pressure chat with one of our knowledgeable solutions experts.

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Additional Insights

Three Potential – And Logical – Waves for Medicaid Modular Modernization
Three Questions To Guide Your Journey to Modularity
Five Dimensions of Change: Predictions for 2021