Strategy and Solutions
The client was a large health plan serving approximately 2.8 million members. Revenue performance depended heavily on achieving high first-pass claim acceptance rates across complex payer rules, EDI formats, and denial prediction models. Leadership committed to a 96% clean claims target but needed rigorous validation before rolling out new RCM logic.
To de-risk deployment and strengthen audit readiness, the health plan partnered with Zymr for large-scale RCM testing and compliance validation.
Claims workflows involved hundreds of payer-specific rules, EDI variations, and denial scenarios. Errors could result in delayed reimbursements, compliance findings, and revenue leakage. The platform also needed to meet enterprise security and audit standards while processing millions of claims reliably.
Zymr helped the health plan validate and launch its RCM platform with confidence. Large-scale testing ensured clean claims performance, improved cash flow, and strengthened compliance posture—directly supporting financial stability and regulatory readiness.
Zymr delivered a comprehensive RCM testing and assurance program at scale.
Security and Compliance Readiness
Supported SOC 2 Type II certification through controls validation and audit evidence.
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