AGI.do

Processes

What will AGI do for Perform medical management?

AI-deliverabilitydigital

Because no child occupations are seeded, this scalar is derived from the APQC process name and its 'Direct Health and Medical Insurance Carriers' industry context. In health insurance, medical management (utilization review, case management, prior authorization) is remotely-doable knowledge work performed entirely via desk-based surfaces (computers, telephones) without hands-on patient care, placing it securely in the digital band.

A member or provider submits a request for service authorization, or population health analytics identify a member requiring targeted care intervention.

Trigger
A member or provider submits a request for service authorization, or population health analytics identify a member requiring targeted care intervention.
Outcome
Medical services are authorized or denied based on clinical guidelines, and high-risk members are actively managed to optimize health outcomes and control costs.

The work itself

Grounded Work Profile

Measured by

  • Authorization Turnaround TimeprocessProfile
  • Medical Loss RatioprocessProfile
  • Hospital Readmission RateprocessProfile
  • Appeals Overturn RateprocessProfile

Key steps

  • Receive service authorization requests and clinical documentationprocessProfile
  • Assess requests against medical necessity and clinical guidelinesprocessProfile
  • Issue approvals, denials, or modifications for requested careprocessProfile
  • Identify members for disease management and case managementprocessProfile
  • Develop and implement individualized care coordination plansprocessProfile
  • Monitor member progress and adjust interventions as necessaryprocessProfile

How AGI delivers it

Four ways AGI delivers for Perform medical management

  • Services-as-Software

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

    Services.do

  • Autonomous Agents as digital employees

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

    Agents.do

  • Business-as-Code

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

    Platform.do

Value flow

How Perform medical management connects

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