In a recent discussion, NelsonHall explored how WNS HealthHelp continues to modernize utilization management (UM) through scalable AI, real-time decision-making, and configurable service models.

WNS HealthHelp’s platform, Consult™, builds on its evidence-based clinical guidance and continues to achieve high ROI and provider satisfaction through automation and more collaborative provider engagement. For example, within cardiology, musculoskeletal, sleep, and surgical services, a health plan leveraging WNS HealthHelp observed a ~50% drop in denial rates while maintaining stable saving levels. It was able to achieve a net direct savings ROI of 4.9 while improving collaboration between providers and reviewers.

Accelerating Clinical Decision-Making Through AI

WNS HealthHelp has accelerated its investment in AI across the workflow's intake and nurse review layers. A core enhancement is integrating an AI engine that processes submitted clinical documents, matches them against guidelines, and returns decisions within minutes. This innovation removes avoidable delays and enables providers to be productive while the patient is still in the office.

Unlike traditional UM models, where nurses manually triage all submissions, WNS HealthHelp’s engine ensures that only nuanced or incomplete cases reach their Tier 2 (Nurse Review) or Tier 3 (Specialty Provider Outreach) sections. As a result, its clinicians, many of whom are active specialists, can focus on high-impact cases that require true peer-to-peer consultation.

A Modular ’Choose Your Own Path’ Model

Health plans are no longer restricted to rigid UM outsourcing arrangements. WNS HealthHelp now offers three service models:

• UM Elite – fully delegated, WNS-managed solution with end-to-end coverage including technology, expert resources, including medical directors, and clinical staff
• UM Plus – shared technology and resources that extend the payer’s internal capabilities
• UM Standard (BPM) – client-run tech stack paired with WNS clinical and operational support.

These flexible models allow payers to align UM support with their internal strategy, whether scaling fast, minimizing abrasion, or improving turnaround time.

WNS HealthHelp also offers flexible pricing models designed to accommodate different levels of engagement. Options include transaction-based pricing, shared savings agreements, and guarantee-based models tailored to performance metrics. This approach enables health plans to align financial risk with service scope and outcome goals, whether they are pursuing full delegation or targeted support. Notably, the pricing structure is particularly attractive to Medicaid plans and smaller regional payers who need high-impact solutions without taking on the cost or complexity of fully managing UM in-house.

Strengthened Partnerships, EMR Integration, and Clinical Content Expansion

WNS HealthHelp continues to expand its reach and interoperability through a strategic partner ecosystem focused on clinical optimization and provider experience. For example:

• With Rhyme and Humana, WNS supports EMR-integrated workflows that simplify case intake and reduce time spent on case creation
• Through its Availity partnership, WNS integrates its portal capabilities into Availity’s front-end interface, allowing providers to initiate authorizations and access clinical resources within a familiar environment
• In collaboration with Anterior, WNS enhances the clinical integrity of its AI engine, leveraging Anterior’s expertise to improve the efficiency of clinical review processes
• The partnership with InformedDNA allows WNS to rapidly scale its genetic testing programs by incorporating best-in-class clinical guidelines and certified geneticists, helping clients manage complex oncology and precision-medicine cases.

Advancing Provider Collaboration and Outcomes

Rather than relying on denials to drive savings, WNS HealthHelp focuses on changing provider behavior through clinical education and consultative engagement. The model uses matched specialists, such as cardiologists speaking with cardiologists to reach agreement on care plans, resulting in lower abrasion, fewer repeat submissions, and improved long-term outcomes.

WNS HealthHelp reports significantly higher net promoter scores than the industry average, driven by its high-touch, consultative approach, and physician-matched peer reviews.

Looking Ahead: Scaling for the Future

WNS HealthHelp is continuing to evolve its offerings with a focus on flexibility, AI integration, and reduced administrative burden for providers and payers alike.

Future roadmap priorities include expanding AI across additional intake and clinical decision layers, enhancing voice automation for call center efficiency, and introducing new analytics capabilities to track order patterns and utilization trends.

WNS is also working to commercialize its internal tools for broader market access, making it easier for payers to adopt individual components (e.g., clinical guidelines engine, nurse AI review, intake automation) as standalone services.

With growing interest from Medicaid and regional health plans, WNS HealthHelp is well-positioned for the next phase of UM transformation by combining proven savings with improved provider experience.