Risk Management
Leverage AI-driven precision to optimize coding accuracy and assess the risk acuity of your population.
The Challenge
Inaccurate risk capture leads to revenue leakage and non-compliance.
Coding gaps
Undocumented conditions result in inaccurate risk scores and lost reimbursement revenue.
Audit exposure
Manual, fragmented documentation increases the risk of costly regulatory compliance penalties.
Data silos
Disconnected clinical and claims data obscure a true 360-degree member view.
Delayed insights
Retrospective analysis identifies risks too late to impact care or financials.
Our Solution
From retrospective analysis to real-time coding precision.
Accurately calculate HCC risk scores to assess patient severity, identify coding opportunities, and enhance risk stratification, with support for CMS HCC versions 24 and 28.
Leverage role-based worklists to pinpoint providers managing high-risk, high-cost patients and uncover key opportunity areas.
Streamline retroactive reviews & audits by accessing member clinical summaries directly from EMRs without leaving the member record
Identify missing codes for recapture, enabling accurate coding and supplemental submission.
Provide suspect code recommendations to improve coding accuracy and assist provider clinical evaluations via point of care intelligence.
Administrative dashboard and worklist to share real-time population risk intelligence with provider offices, pushing clinical diagnosis gaps and coding opportunities for actioning.
Agentic AI
Our AI agents accelerate risk management.
Risk Adjustment Coding Agent
Identifies and applies accurate risk codes to ensure proper reimbursement.
Care Plan Recommendation Agent
Prior Auth Review Agent
Accelerate medical review cycles and reduce administrative costs through intelligent automation.
Document Review Agent
Reduce processing time and rework by automating document validation and completeness checks.
Gap Closure Agent
Improve quality scores and incentive performance through proactive, data-driven gap identification.
Benefits Review Agent
Enhance member value and reduce unexpected costs through real-time tracking and optimization of insurance benefits.
Data Platform
Our Unified Data Platform is the foundation of our solutions
Unified
data
Harmonize fragmented data into a platform built for healthcare to ensure seamless integration and effortless data management.
Actionable
intelligence
Trigger both human and automated interventions at the right moments to improve quality, reduce administrative burden, and lower medical costs for over 43 million lives.
Event-driven
workflow
Deliver personalized, context-rich workflows by transforming data into real-time insights and eliminating unnecessary administrative tasks through automation.
Case Studies
See how we’ve helped others with risk management.
HarmonyCare Health Plan
“From day one, Medecision treated us like partners, not just clients. Their implementation team made onboarding smooth and surprisingly fast, and their support team continues to feel like an extension of our own staff.”
Hawaii Medical Service Association
“I’ve enjoyed working with the Medecision team since 2003. They’re very professional, knowledgeable and energetic. They inspire me to go the extra mile, to work harder. We started years ago with utilization management workflow, administration and reporting. By listening to customer feedback, Medecision has a positive impact on healthcare. Its solutions and services continue to help us achieve our vision of building a healthier, happier Hawaii.”
Health Home Partners of Western NY
“We were able to leverage the technology to help us find our patients, evaluate acuity, prioritize and coordinate actions, even when all other services were down.”
Brand New Day
“We’re always looking for ways to make our technology do more, and Medecision is a big help. We were able to configure our system to process authorizations much more easily for all of our Medicare Advantage members. Our physicians flock to Medecision once they learn their members’ risk scores – including pharmacy and lab data – are there and that they can automate their own authorizations. We all like the idea of having everything coordinated in one system. That’s Medecision.”