Beyond automation: Optimizing siloed workflows with unified clinical AI

Overview:

Health plans have long operated in silos, with utilization management (UM), payment integrity, and other core functions using disconnected data that lead to inefficiencies, inconsistencies, and administrative burden.

At Becker's 4th Annual Spring Payer Issues Roundtable, leaders from Medical Mutual, AmeriHealth Caritas, and Cohere Health explored how unified clinical AI can connect and optimize these silos, transforming some of the most burdensome payer operations.

The Cohere-sponsored panel, Beyond automation: Optimizing siloed workflows with unified clinical AI, highlighted how clinical intelligence is streamlining workflows while laying the groundwork for more proactive, member-centered care at scale.

Key themes from the conversation:

1. Siloed workflows and data create major pain points for stakeholders

• Legacy prior authorization workflows require UM teams to manually navigate numerous silos for the right information, leading to delays, denials, and friction.
• Poor data interoperability makes UM one of the most error-prone, burdensome processes for both payers and providers.

2. Clinically intelligent AI can modernize UM and other burdensome operations

• Cohere Health's clinical intelligence platform connects clinical and administrative data and drives real-time decisions, helping payers streamline operations and improve member care access.
• With unified data, the platform can surface holistic member insights-enabling payers to automatically identify and engage members with the right proactive or wraparound services, and strengthen historically strained provider relationships.

3. Payers should evaluate AI vendors for adaptability, integration strength, and clinical depth

• Multi-state plans like AmeriHealth require AI technology partners capable of adapting their AI for various state requirements.
• Another key consideration is a vendor's ability to integrate with payers' existing data and technology stacks for a seamless automation architecture.
• The ideal AI vendor combines deep healthcare expertise with clinically led technology, empowering them to best support health plans' business goals and scale their partnership as strategic needs evolve.

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