Clinical reviewers open a utilization management or appeals case and spend most of it assembling evidence — hundreds of pages, several source systems and a fax queue that has outlasted every modernization plan built around it. The determination itself is the fast part.
This session walks through a different sequence. AI assembles the record into a case summary with in-text citations, and the reviewer checks each line against the original document side by side. The software gathers, retrieves and cites. The nurse reviewer or medical director decides.
The walkthrough covers what the workflow leaves behind as much as what it produces, along with the measures health plans are watching as they scale it.
In this session, you’ll learn:
- What a reviewer actually sees when verifying a generated summary against a several-hundred-page source record
- Where the human stays in the loop by design, including captured overrides and reviewer feedback that sharpens later summaries
- Which artifacts the workflow produces for compliance, from in-text citations and version history to role-based access and an audit trail built for CMS program audit scrutiny
- Which measures health plans use to judge it, including review time per case, turnaround against decision timeframes, first-pass accuracy and overturn rate