Agents that learn your UM reviewers.
Requests arrive faster than reviewers can work them, and every one carries a turnaround clock. The agent learns how your nurses read a case and carries it to the point of decision.
Where the time goes
Requests arrive by fax, portal, and EDI, and each must be matched to a member, plan, and benefit. Submitted clinical documentation is unstructured, and gets read end to end before criteria can be applied. Regulatory turnaround clocks run whether or not the queue is staffed.
What the agent takes on.
Learns what your reviewers look for in each request type, and what makes them pend rather than approve Intakes the request, matches it to the member, plan, and benefit, and confirms eligibility Reads the submitted documentation and pulls what the applicable criteria call for Applies the criteria and lays out where the record supports the request and where it falls short Files the decision and generates the notice once your reviewer signs
Where your reviewers decide
The agent lays out the case with its reasoning: what the criteria require, what the record shows, and where the two diverge. Your reviewer decides on that evidence You set the guardrails: which request types, dollar thresholds, or confidence levels a person must sign Adverse decisions stay with a medical director, as regulation requires Every request, criteria check, and notice lands in the audit trail with its turnaround clock