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Utilization Management Re‑imagined
Powered by CareAssistant.ai – the Agentic AI engine from CareInsight
Prior auths and clinical reviews—handled at machine speed, governed with human empathy
Our UM module fuses large‑language‑model reasoning, deterministic clinical rules, and autonomous task agents to turn legacy fax queues into a friction‑free, evidence‑based workflow for providers, members, and medical directors alike.
| Challenge | Traditional Workflow | With CareInsight |
|---|---|---|
| Turn-around‑time (TAT) | 3–5 days for routine auths | Median < 8 hours, STAT in < 30 min |
| Provider abrasion | Endless phone tags & fax resends | Real‑time portal + EDI 278 auto‑ACK + chatbot status |
| Clinical consistency | Human variability, missed guidelines | LLM cites InterQual/MCG & plan policy, same every time |
| Audit readiness | Manual spreadsheets for NCQA UM 3/4 | Immutable logs, letter libraries, and timer boards |
| Operational cost | 20–30 min analyst touch‑time | Agent drafts & routes; analyst spends < 6 min per case |
Core Capabilities
Autonomous Case Agents
Each prior‑auth request spawns an agent that ingests clinical notes (CCD, PDF, fax OCR), matches to the correct policy, queries missing data, and assembles a recommendation for RN/MD sign‑off.
Evidence‑Linked Decisions
Our healthcare‑tuned LLM references current InterQual, MCG, NCCN, and proprietary plan policies, embedding citations directly in the letter and audit log.
Interactive Analytics
Dashboards show denial reasons, turnaround variance, provider hot‑spots, and avoidable emergency admits—exportable for UM committee decks.
Predictive Workload & Staffing
ML models predict daily auth volume and flag cases likely to require peer review, helping leaders right‑size staffing before the queue spikes.
NCQA & CMS Compliance Out‑of‑Box
Built‑in workflows for UM, denial notice templates, and configurable decision timers.
Low‑Code Customization
Drag‑and‑drop rule editor for benefit carve‑outs, episodic bundles, and value‑based payment triggers—no SOW needed.
Multichannel Smart Intake
X12 278, portal, SMART‑on‑FHIR, fax, voice—one queue; AI extracts CPT/ICD‑10, urgency, clinical indicators, and routes instantly.
Dynamic Medical Necessity Letters
Auto‑generated in plain language, ≥ 8th‑grade reading level, in English + 26 languages, delivered via portal, secure email, or batch.
Proactive value based care
