SHMS Optimizes Operations for Medicare Advantage Plan Operators in the Healthcare Payer Enterprise
This episode of I Don't Care explores how Strategic Healthcare Management Systems (SHMS) helps small and midsize Medicare Advantage plan operators navigate the technical and regulatory demands of the healthcare payer enterprise. CEO Chris Stanley discusses how SHMS's vertically integrated platform automates compliance, claims adjudication, and risk adjustment, enabling organizations to go live within four months. The conversation also covers SHMS's roadmap for integrating AI into fraud detection, contract optimization, and risk adjustment.
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Key takeaways
SHMS automates Medicare Advantage plan operations—including CMS risk submissions and audits—reducing adjudication staff needs by up to 90%.
The platform guides startup and midsize payer organizations from licensure to go-live in as little as four months.
SHMS is developing AI capabilities for fraud detection, contract optimization, and risk adjustment to future-proof payer operations.
Enrollment in Medicare Advantage plans is projected to reach about 35.7 million, according to a 2025 Senate Finance Committee report. Yet, many startup and midsize organizations face steep technical and regulatory hurdles when launching or scaling operations. As part of the broader healthcare payer enterprise landscape, these plans must manage compliance, claims adjudication, risk adjustment, and reporting. This requires robust software systems that can handle increasing complexity without driving up overhead.
How can small and midsize organizations offering Medicare Advantage plans compete and scale effectively in a highly regulated, data-heavy environment?
On this episode of I Don’t Care, host Dr. Kevin Stevenson welcomes Chris Stanley, CEO and founder of Strategic Healthcare Management Systems (SHMS), for a deep dive into the software and operational needs of the healthcare payer enterprise. They explore how the company helps payer organizations manage everything from enrollment and risk adjustment to claims automation and regulatory reporting through a vertically integrated platform that scales fast.
Key Highlights
- Automating Compliance and Operations: SHMS enables 90% reductions in staff needs for adjudication by automating plan operations, CMS risk submissions, and audits.
- Supporting Startup and Mid‑Sized Organizations: The company specializes in guiding small and midsize organizations within the healthcare payer enterprise from licensure through go-live, often within four months.
- Future‑Proofing with AI: Stanley outlines plans to integrate AI for fraud detection, contract optimization, and risk adjustment—moving from proof of concept toward scalable innovation.
Christopher Stanley is the CEO and Founder of Strategic Healthcare Management Systems, where he has spent nearly two decades building scalable software solutions for Medicare Advantage and payer operations. His career spans roles in software engineering, product management, and healthcare IT at organizations including WebMD, RATA Associates, and Informa. He specializes in helping healthcare payer organizations streamline operations and meet compliance standards, with deep expertise in data systems, claims processing, and regulatory reporting.
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