Member-Centric Architecture
The Medecision Platform is designed around a foundational principle: every object, interaction, rule, and event is anchored to a single, unified member record. This architecture ensures that all data, workflows, and automation logic contribute to a longitudinal, real-time understanding of each member’s journey across care, utilization, outreach, and regulatory functions.
Core Principle: Member as the Source of Truth
Each member in the system has a unique ID and serves as the central node for all related entities:
Programs (Care Management, Appeals, UM, Engagement)
Tasks and assignments
Requests (Authorizations, Appeals, Grievances)
Assessments and screenings
Outreach history (digital or telephonic)
Clinical data (claims, ADT, SDOH, risk)
Correspondence and letters
Notes, timeline events, and interactions
This design allows for a 360-degree, real-time, and auditable record for each member.
Member Profile Data Model
The Member Profile aggregates and synchronizes multiple data domains:
Key Sections
Demographics: Name, DOB, gender, race, ethnicity
Eligibility: Payer info, coverage periods, PCP, risk stratification tier
Contact Info: Addresses, phone, language, communication preferences
Identifiers: Member ID, plan ID, internal UID, external mappings
Linked Entities: Programs, Tasks, Requests, Assessments, Outreach History
Data Sources
Eligibility and enrollment files
Claims and provider data
Social determinants and community data
ADT and HL7 feeds
FHIR-based API integrations
The profile updates automatically when new data is received via file feeds or APIs.
Comprehensive Member View (CMV)
The CMV is the platform’s core UI surface for viewing and interacting with a member’s full history.
Features
Chronological Timeline of all system and user activity
Visual indicators of active programs, open tasks, requests, and TAT risk
Filters by module (Care Management, UM, Digital Outreach, Appeals)
Linked assessments, letters, and call notes
Real-time updates and auto-refresh
Interaction Use Cases
Care managers reviewing member engagement before outreach
UM reviewers verifying prior authorizations tied to other programs
Compliance teams auditing appeals resolution steps
All items on the CMV are clickable and support drill-down into full detail views.
Timeline Architecture
Every event or interaction tied to a member is recorded on their timeline.
Types of Entries
Program enrollment or stage progression
Task assignments, completions, escalations
Assessment completions and results
Request status updates (e.g., submitted, in review, resolved)
Outreach messages sent (email, SMS, IVR)
Correspondence generation and delivery
Notes, calls, and user interactions
Technical Design
Indexed by event type, date/time, actor (system or user)
Fully filterable and auditable
Integrated with reporting and event-based triggers
Role-Based Views and Access
Access to member data is role- and context-aware:
Care Managers see care programs, tasks, assessments
UM Nurses see requests, decisions, peer reviews
Outreach Coordinators see campaign history, journey steps
Compliance staff see appeals, grievances, and correspondence
Permission sets control edit/view rights across modules. Audit logs are maintained at every interaction.
Integration with Builders
The member-centric model is tightly integrated with builder tools:
Rules Builder: Conditions evaluated against member data (e.g., age, risk tier, program status)
Program Builder: Uses member attributes to trigger eligibility or progression logic
Assessment Builder: Launches member-specific screens, prefilled with known data
Journey Builder: Sends outreach based on member preferences and timeline activity
FHIR & API Alignment
The platform exposes member data via both REST and FHIR APIs:
GET /member/{id}: Full member profileGET /member/{id}/timeline: All associated eventsPOST /member/{id}/request: Submit a new prior authPATCH /member/{id}: Update member attributes
APIs support integration with external EMRs, HIEs, call center systems, and payer portals.
Member Identity Resolution
The platform supports:
Use of external master member index (MMI)
Client-specific member IDs or internal UIDs
Multiple identifier types per member (e.g., Medicaid, Exchange, Medicare)
Deduplication via deterministic and probabilistic matching
This ensures consistency even across multiple plans, lines of business, or incoming data sources.
Analytics & Reporting
Because every object is tied to the member, downstream analytics can:
Measure engagement across programs per member
Track request turnaround and resolution time by member cohort
Compare outcomes by SDOH, age, or geography
Visualize longitudinal clinical activity (e.g., IP admits, risk scores)
Compliance and Auditability
All user/system changes to member data are logged
Correspondence and decisions tied to requests/programs are date-stamped
Reporting extracts include full member history and associations
This architecture powers all workflows in the Medecision Platform by ensuring that the member is always the single source of truth. Every builder tool, decision engine, and user interface is optimized to reflect and act on the member's complete context.