Digital innovations continue transforming the healthcare industry, driving operational efficiency, reduced costs, and improved outcomes. The integration of advanced software proves particularly beneficial for payers, reducing administrative costs by up to 18% and improving diagnostic accuracy by 15%.
Payers must stay informed about emerging technologies and notable products to tap into these benefits. This article reviews the following leading healthcare payer software options:
Payers are health plan providers that set payment rates, collect premiums, and process claims — and they rely on technology to complete these tasks efficiently. Payer software is specialized technology that streamlines payer operations by providing actionable insights from member data.
Payer solutions leverage data from numerous sources to power functionalities across market segments, including:
Care management: Payer solutions include care management tools to support resource allocation, data integration, and reduced healthcare costs
Quality measurement: Comprehensive software monitors cost efficiency, clinical outcomes, and other data points to help payers inform care improvements
Claims: Payer software enables payers to address health demands by analyzing utilization, costs, and effectiveness across claims data
Risk adjustment: The right platform equips payers to identify high-risk members, allocate resources fairly, and achieve equitable financial arrangements
While the above features are valuable tools for any payer solution, organizations must assess software options to determine which platform addresses their unique challenges. Resources such as software reviews, industry awards, and educational materials on payer strategies can support your research.
Arcadia is the leading provider of healthcare payer software, offering data solutions that extract actionable insights from operations, claims, enrollment, and ancillary data to inform health plan and service adjustments. As a top-rated vendor for healthcare analytics, this platform stands out for its multi-source data aggregation, advanced analytics, and workflow automation.
Combines clinical and claims data to achieve a 4% lift in risk and ~.3 higher Star Ratings points
Surfaces new insights and trends that highlight areas of improvement using machine-learning analytics
Automates claims processing, utilization review, and care management workflows to accelerate decision-making
Notably, Arcadia’s newly launched solutions yield significant benefits for payers:
Enhanced Benchmarks: This solution enables organizations to identify performance gaps and improvement opportunities by comparing market-based cost, utilization, risk, and quality benchmarks to their own performance
Arcadia Vista Push: This solution automates enterprise-wide performance reporting, enabling payers to deliver data-driven insights that support better decision-making
A recent study highlights Arcadia as the population health vendor that received the most consideration for purchase between July 2022 and June 2024 — and that’s not where the platform’s accolades end.
Arcadia was recognized as the Best New Enterprise Version of the Year at the 2024 Best in Biz Awards. The platform also received a 2025 BIG Innovation Award in the healthcare product category for its leadership in driving innovative solutions for healthcare transformation.
Gainwell Technologies supports commercial healthcare payers through its cloud-enabled cost containment and care quality solutions. Through automation and standardization features, this solution empowers payers to operate efficiently and sustainably over the long term.
Gainwell Technologies serves over 175 commercial payers and offers decades of experience addressing health organizations’ most common challenges.
Based in Plano, Texas, ZeOmega offers comprehensive technology solutions for care management, process automation, organizational optimization, and overall efficiency. Its healthcare payer platform, Jiva, delivers advanced insights into cost and quality through sophisticated data integration.
Jiva can also auto-generate care plans, optimizing payer workflows and patient outcomes.
Medecision touts a four-times faster rate of improving health outcomes, reducing costs, and personalizing engagement through its data-powered platform. Its HITRUST CSF-certified SaaS solution, Aerial, delivers real-time insights to help payers engage with individuals at critical health moments.
Aerial supports healthcare organizations under MSSP, Medicare Advantage, fee-for-service, commercial, and value-based care contracts.
HELIOS by VirtualHealth is a comprehensive care management platform that handles large groups of members. Its customizable interface supports specialized care management for diverse populations, boosting results for payers and patients alike. This solution also offers robust care, disease, and utilization management capabilities to help you increase staff productivity.
As a HITRUST CSF-certified solution, HELIOS is a promising payer software option.
EXL is a digital operations company with an analytic-enabled care management platform, CareRadius. This solution provides seamless access to real-time data, improving payer decision-making, workflows, and cost management.
CareRadius is also highly flexible, allowing health plans to implement custom workflows and rules based on the organization’s needs.
The GuidingCare Solution Suite, offered by HealthEdge, is a set of data integration and workflow management tools that enables payers to maintain compliance while serving targeted populations. This NCQA measure-certified platform includes capabilities for care management, utilization management, provider authorizations, appeals and grievances, population health management, and business intelligence.
Chordline Health’s managed care and population health platform, ACUITYnxt, unlocks data-driven clinical information that drives improved outcomes and lower costs. This healthcare payer software offers population health analytics, clinical program support, and other key features to help transform payers’ approaches to managed care.
While other providers emphasize an effort to access real-time data, Cognizant empowers payers to look toward the future. TriZetto Unify is Cognizant’s platform for faster provider-payer communication, enabling timely interoperability that complies with HL7 FHIR regulations.
Cognizant’s portfolio of functionalities also includes provider reimbursement solutions, quality management, and administration to help boost payer efficiency.
While SS&C Technologies works across a broad spectrum of industries, the company has over 30 years of experience collaborating with health organizations. SS&C aims to enable digital connectivity through digital engagement tools, total cost of care analytics, and other innovative solutions. This provider’s AI-driven intelligent automation technologies enable payers to digitize and classify documents while mitigating operational risk.
CareSpace is Persivia’s AI-powered, end-to-end comprehensive solution that empowers payers to excel by managing data, analytics, quality, and risk. This solution integrates clinical, claims, and SDOH data to help payers identify vulnerable populations and engage in timely care coordination. It utilizes natural processing language (NLP) and machine learning to automate the risk adjustment process, streamlining payers’ workflows.
Healthcare payer software is a vital tool for workflow optimization, quality care delivery, and overall improved health outcomes. While these tools yield benefits across the care continuum, payers must choose solutions that align with their organizational priorities and needs to make the most of the platform.
Conduct thorough research before committing to a solution. Requesting a demo of your top choices provides an in-depth look at potential solutions, enabling you to make an informed decision. By choosing the right software, payers drive the future of value-based care.