Risk Management
Leverage AI-driven precision to optimize coding accuracy and assess the risk acuity of your population.
Features
Accurate and compliant member risk coding
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.
Take a Closer Look
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.
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.
Featured
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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