High-Cost Member Management

In most health plan books of business, 5 percent of members account for 50 percent or more of total medical expenditure. These members are not unknown to the plan. Actuarial risk models identify them. Complex case management programs enroll the highest-acuity tier. The identification infrastructure is well-developed. The outreach infrastructure that is supposed to follow it is not.

High-utilizer members present specific engagement challenges. Many have fragmented care relationships — multiple specialists, frequent care transitions, gaps between inpatient and outpatient follow-up. Many have significant social needs that affect their willingness and ability to engage with the health plan. A call that opens with a scripted introduction and does not immediately demonstrate familiarity with their clinical situation does not generate engagement.

Case management staff managing complex member caseloads are typically among the most clinically skilled in the plan's care management workforce. Their time is most valuable in the interactions that require clinical judgment — care plan development, specialist coordination, high-stakes transitions. It is least valuable in the routine monthly check-in contact that is required to maintain program enrollment and catch emerging issues before they become acute events. That is where consistent outreach breaks down.

ZynPredict identifies members whose utilization and clinical signals indicate a rising trajectory — not just the members already in high-tier case management, but the members approaching that threshold. The Predictive Activation Agents initiate outreach for rising-utilizer members before the next admission, capturing medication status, identifying social barriers, and routing concerns to the case management team with full context.

For members already enrolled in complex case management programs, the Chronic and Longitudinal Care Management Agent maintains the routine monthly outreach cadence — confirming medication adherence, checking for new symptoms, reinforcing care plan components, and identifying barriers that need case manager attention. The case management team receives escalations from the routine contact rather than owning the contact volume itself.

For health plan care management and medical management teams, the change is in how caseload hours are distributed. Case managers spend their time on the high-judgment interventions. The routine contact volume that keeps members engaged between those interventions runs through the Zynix AI workflow.