The Challenge
A burgeoning analytics group within a health insurer was responsible for triggering members
for clinical interventions. As new business grew, the team relied on a fragmented collection of
scripts to identify and trigger members — an approach that had become unsustainable.
Redundant, Duplicated Code
A scattered collection of scripts with identical functionality repeatedly recoded across files.
Hard-Coded Criteria
Cohort parameters like ICD-10 codes were buried in scripts, making triggering criteria hard to understand.
Minimal Traceability
Little tracking of member activity or justification for triggering, creating a daunting QA challenge.
Unable to Scale
The system could not keep up with the growing volume of new cohort requests from a steady influx of business.
The Solution
We introduced a comprehensive, database-driven member identification and triggering system,
meticulously designed to manage targeted outreach for hundreds of cohorts of at-risk members.
An intuitive GUI lets analysts define cohort parameters and review past triggers —
including who was triggered and why.
Define Cohorts in a GUI
A broad spectrum of system parameters made available through the interface — clinical codes, member counts, lookback periods, and exclusion criteria.
Define
Set cohort parameters in the GUI — ICD-10 and HCPCS codes, member counts, and lookback periods.
Identify
The database-driven engine identifies eligible members and applies exclusion criteria.
Trigger
Members are triggered for outreach and pushed to integrated case management systems.
Review
Every trigger is logged for analytical review — who was triggered, and exactly why.
A single, auditable path from cohort definition to outreach — replacing hundreds of one-off scripts with a repeatable, transparent workflow.
Database-Driven Engine
Cohort logic and parameters live in the database rather than scattered scripts, making triggering criteria clear and consistent.
Robust Developer Tools
Function libraries and APIs give developers reusable building blocks and seamless integration with case management systems.
Built-In Auditability
Every trigger is tracked with its justification, turning a daunting QA challenge into a transparent, reviewable record.
Operational Cornerstone
Now the cornerstone of operations for a 30+ member team and used daily by over 10 developers.
Results
The platform replaced an unsustainable web of scripts with a single, scalable system —
freeing developers, accelerating new cohort delivery, and opening a new line of business.
No-Code Cohort Definition
Cohorts that previously demanded extensive scripts can now be defined directly in the GUI, eliminating the need for coding.
Freed-Up Developer Time
With cohort definition off their plates, developers are freed to focus on more critical, higher-value tasks.
Scales With New Business
Manages targeted outreach for hundreds of cohorts of at-risk members and absorbs a steady influx of new requests.
Transparent & Auditable
Analytical review of past triggers makes quality assurance straightforward, with clear visibility into who was triggered and why.
Commercialization
The success of the member identification system created a new opportunity for the client:
extending the triggering service to other organizations as a commercial offering.
A New Revenue Stream
A purpose-built internal tool became a service the client could monetize and offer to outside organizations.
Triggering as a Service
The same database-driven engine and GUI now power clinical intervention triggering beyond the original team.
This was one of the most impressive systems I’ve seen in my 21-year career.
David, Senior Developer
The system is sooo easy to use.
Victoria, Business Analyst
