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Cut Care Management Costs 40%
Never Miss an HRA, ICP, or Transition Deadline Again
End-to-end AI workflow from member identification through care plan execution — built for SNP, MA, and Medicaid compliance.
What Are Care Management AI Agents?
Care Management AI Agents automate the full member lifecycle from dynamic risk identification and mandated outreach through federally required care plan generation and real-time remote monitoring. They replace manual nurse workflows with intelligent, scalable AI that meets every SNP, MA, and Medicaid compliance requirement while dramatically reducing operational cost.
Unlike point solutions, CareInsight’s Care Management Agents operate as a connected end-to-end workflow Identify, Engage, Plan, and Monitor on a single platform with every interaction documented, timestamped, and audit-ready.
Our Care Management AI Agents
Identification & Stratification Agent
Dynamically identifies and stratifies members into risk tiers (Low / Moderate / High) using claims, HRA, and unstructured EMR data — not just annual static snapshots. Incorporates CMS-HCC risk scoring and goes beyond what health plans typically achieve by including EMR data most plans miss. Supports NCQA SNP approval requirements and state EQRO reviews under 42 CFR §422.101(f) and §438.208.
Continuous dynamic stratification replaces the static annual process — ensuring your highest-risk members are always identified and actioned in real time, not 12 months later.
Outreach Agent
AI-powered outbound calls and omni-channel outreach (SMS + voice, multi-language) for HRA completion, comprehensive needs assessments, SDoH screening, behavioral health assessments, MTM reviews, gaps in care, transition of care contacts, and chronic disease management. Delivers multiple automated attempts with full documentation for audit. Mandated initial HRA within 90 days of enrollment (42 CFR §422.101), with 30–45 day priority for high-risk members.
Reduces per-outreach cost from $12 to $3 — a 75% savings — with multiple automated attempts replacing manual nurse calls. Full documentation ensures audit readiness for CMS Model of Care reviews.
Clinical Summary Agent
Connects all data sources — claims, EMR, HIE, labs, pharmacy — into a comprehensive AI-generated clinical summary for care managers, medical directors, and coordinators. Meets CMS Interoperability Final Rule requirements (CMS-0057-F). Replaces fragmented manual data assembly with a single, timely, complete member view across all care touchpoints.
Saves 80% of the time clinicians currently spend assembling fragmented data manually — giving care managers immediate visibility into the full member picture to act faster and more accurately.
Individualized Care Plan Agent
Auto-generates federally mandated ICPs including Goals, Problems, Interventions, Milestones, and Patient / Care Manager / Provider actions. Required under 42 CFR §422.101(f) for SNPs and 42 CFR §438.208(c) for Medicaid — with a 30-day SLA post-assessment. Replaces a fully manual process that currently takes 60–90 minutes per plan at $1.15/minute in nurse time.
Reduces ICP creation from 60–90 minutes to under 15 minutes — delivering 80% cost savings ($50+ saved per plan). More accurate than manual documentation with guaranteed 30-day SLA compliance. Previously only done for high-risk members; now scalable across all tiers.
Remote Patient Monitoring Agent
Integrates any RPM device for real-time, context-based alerts tied to individual member conditions. Feeds live vitals data directly into care management workflows for proactive intervention. Enables new revenue capture via CPT billing: 99453 (Initial Setup), 99454 (Device Supply — 16+ days/month), 99457 (First 20 min clinical staff time/month), 99458 (Each additional 20 min). Supported by 40+ states for Medicaid reimbursement.
Transforms care management from reactive crisis response to proactive intervention. Unlocks significant additional revenue through CPT 99453–99458 billing — currently uncaptured by most plans — while improving STAR ratings and reducing costly acute care events.
Omni-Channel Engagement Agent
Enables unified member and provider communication across voice, SMS, email, and mail with full conversation tracking and automation. Supports outreach, reminders, care coordination, A&G notifications, and follow-ups — all in one platform with multi-language capabilities and real-time engagement tracking.
Eliminates fragmented communication systems by centralizing all interactions into a single compliant workflow — improving member engagement, reducing missed touchpoints, and ensuring every interaction is documented and audit-ready.
End-to-End AI Workflow
Why Health Plans Are Moving Now
- HRA: 90-day mandate (§422.101) — 30–45 days for high-risk members
- ICP: 30-day SLA post-assessment (§438.208) — states enforcing actively
- Digital clinical summaries now required for every member (CMS-0057-F)
- NCQA Model of Care + state EQRO audits demand full documentation chain
- Manual HRA outreach costs $12/attempt × thousands of members
- Nurses at $1.15/min spending 60–90 min on manual care plans
- Missed HEDIS/Star measures = $10M–$50M/yr in lost quality bonuses
- Uncaptured RPM billing (CPT 99453–99458) = millions in lost revenue
- 40% care management staff reduction within 90 days — proven
- Dynamic stratification using data sources most plans miss (EMR)
- Full workflow: Identify → Outreach → ICP → Monitor in one platform
- Every interaction documented, timestamped, and audit-ready
Where CM Agents Shine
Supporting Care Planning and Risk Tracking
Risk Stratification & Cohort Management
HRA & Assessment Outreach Automation
Individualized Care Plan Generation
Remote Patient Monitoring & Alerts
AI Clinical Summary & 360° Member View
Transition of Care Outreach
MTM Tracking & Medication Adherence
SDoH Screening & Community Navigation
HEDIS / Star Gap Closure
CMS Model of Care & NCQA Audit Readiness
Why Choose Us
Ready to Transform Care Management?
Request a personalized analysis see exactly what CareInsight saves your plan.
Ready to Transform Care Management?
Request a personalized analysis see exactly what CareInsight saves your plan.
