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Processes

What will AGI do for Perform utilization management?

AI-deliverabilitydigital

With no child occupations seeded, this scalar is derived from the process name ('Perform utilization management') and its anchored industry ('Direct Health and Medical Insurance Carriers'). Utilization management involves evaluating authorization requests and medical records against clinical guidelines to determine medical necessity. This is entirely screen-based information processing and knowledge work, which firmly places it in the digital band.

A healthcare provider or member submits a request for prior authorization or coverage approval for a specific medical treatment or service.

Trigger
A healthcare provider or member submits a request for prior authorization or coverage approval for a specific medical treatment or service.
Outcome
The requested medical service is evaluated for medical necessity and a formal coverage decision is communicated to the provider and member.

The work itself

Grounded Work Profile

Measured by

  • Authorization Turnaround TimeprocessProfile
  • Initial Denial RateprocessProfile
  • Peer Review Escalation RateprocessProfile
  • Appeal Overturn RateprocessProfile

Key steps

  • Receive authorization request and verify member eligibilityprocessProfile
  • Collect required clinical documentation and medical recordsprocessProfile
  • Review clinical details against established medical necessity criteriaprocessProfile
  • Route complex or pending denial cases to a medical director for peer reviewprocessProfile
  • Issue formal approval or denial decisionprocessProfile
  • Notify the provider and member of the coverage determinationprocessProfile

How AGI delivers it

Four ways AGI delivers for Perform utilization 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 utilization management connects

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