Quality Management

Drive Quality Performance and Close Gaps with our AI-powered engine.

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Quality Management

Features

Improve population health
and scale quality programs

Streamline compliance with an engine built to calculate and track industry-standard quality measures like HEDIS with precision.

Streamline retroactive reviews & audits by accessing member clinical summaries directly from EMRs without leaving the member record.

Track quality gaps across your population with role-based worklists, enabling targeted interventions and scaled quality improvement efforts.

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Quality Management

Agent Spotlight

Care Plan Recommendation

Boost care team efficiency and reduce avoidable costs through personalized, evidence-based guidance.
Generates evidence-based, personalized care plans that improve clinical outcomes and care coordination.

Call Review

Drive operational efficiency by automating call analysis to uncover high-impact care opportunities.
Analyzes call transcripts to surface care management opportunities, ensuring timely intervention and better member engagement.

Program Advisor

Improve program ROI and population health by directing members to the most effective care pathways.
Recommends optimal care programs by analyzing claims, clinical, and engagement data to drive improved health outcomes.

Medical Summary

Cut review time and enhance program recommendation accuracy with a unified, AI-driven view of member data across the platform.
Delivers an integrated member clinical summary with next-best-action insights to guide more informed, efficient care decisions.

Prior Authorization Review

Accelerate medical review cycles and reduce administrative costs through intelligent automation.
Evaluates clinical records against medical policies to determine medical necessity, highlight key evidence, and accelerate authorization decisions.

Document Review

Reduce processing time and rework by automating document validation and completeness checks.
Automates validation of submitted clinical documents to ensure completeness, reduce delays, and support faster, compliant reviews.

Featured

Gap Closure

Improve quality scores and incentive performance through proactive, data-driven gap identification.
Identifies open care gaps and recommends targeted actions to boost quality scores, compliance, and member outcomes.

Risk Adjustment Coding

Increase reimbursement accuracy and coding compliance while reducing manual review burden.
Detects and applies accurate risk codes to improve documentation integrity, compliance, and reimbursement accuracy.

AgentFoundry is our healthcare native Agentic AI Platform with a library of pre-built agents.
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