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Processes

What will AGI do for Manage and Process Risk Adjustments?

AI-deliverabilitydigital

With no child occupations seeded for this composite, the scalar is derived entirely from the process name ('Manage and Process Risk Adjustments') and its anchoring industry lens ('Direct Health and Medical Insurance Carriers'). Managing risk adjustments is fundamentally an information-processing activity involving financial modeling, medical data analysis, and regulatory submissions. As pure knowledge work lacking physical tasks, it sits firmly in the digital band at a center value of 0.85.

Receipt of updated member clinical and claims data or the start of a regulatory risk adjustment reporting cycle.

Trigger
Receipt of updated member clinical and claims data or the start of a regulatory risk adjustment reporting cycle.
Outcome
Member risk scores are calculated, validated, and submitted to regulators, resulting in accurate financial compensation adjustments based on population health risk.

The work itself

Grounded Work Profile

Measured by

  • Risk Score AccuracyprocessProfile
  • Data Submission Acceptance RateprocessProfile
  • Coding Audit Pass RateprocessProfile
  • Risk Adjustment Revenue VarianceprocessProfile

Key steps

  • Ingest member claims, encounter data, and clinical recordsprocessProfile
  • Identify and extract hierarchical condition categories (HCC) and relevant diagnosesprocessProfile
  • Validate diagnosis coding accuracy against supporting clinical documentationprocessProfile
  • Calculate individual and aggregate member risk scoresprocessProfile
  • Submit formatted risk adjustment data to regulatory agenciesprocessProfile
  • Reconcile regulatory feedback and financial adjustments with internal revenue projectionsprocessProfile

How AGI delivers it

Four ways AGI delivers for Manage and Process Risk Adjustments

  • Autonomous Agents as digital employees

    Hire a digital employee that does the job under earned, supervised autonomy.

    Agents.do

  • Services-as-Software

    Get the professional outcome delivered as software, priced on results, not headcount.

    Services.do

  • Business-as-Code

    Encode how your work runs, once, as software that executes itself.

    Platform.do

Go deeper

Explore Manage and Process Risk Adjustments

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