GenAI Nurse Assist to Achieve Efficiencies, Faster Care
About the Client
- Plan Type: Multi-Line (Commercial and Medicare Advantage)
- Plan Size: 400K members
- Geography: Midwest
Issue
A leading national insurer was struggling with costly care delays and mounting frustration tied to one critical process: prior authorization.
Clinicians were overwhelmed by administrative work, while members and providers were left waiting for answers. The challenges included coding reviews and nurse reviews for healthcare payers, specifically:
- Delays in treatment
- Resource-intensive manual reviews
- Compliance risks
- Administrative fatigue
- Rising data volumes
- Increased operational cost
In addition, the teams had difficulty maintaining efficient communication between coding teams and nurses, adapting to evolving industry standards and technology, addressing the increasing volume of healthcare data, and maintaining compliance with privacy and security regulations.
Action
Sagility answered with AI technology, clinical expertise, and process excellence.
We launched Nurse Assist, a purpose-built AI solution that transformed prior authorization and utilization management through an agentic ecosystem equipped with automation and clinical intelligence.
Core features include:
- Automated review and coding assistance
- Real-time decision support
- Clinical documentation improvement (CDI)
- Resource optimization
These features enabled the following benefits:
- Automating Coding Assistance
- Generative AI suggested accurate codes based on analyses of medical records, reducing coding error occurrence.
- Achieving Real-time Decision Support
- AI provided real-time decision support to nurses and coders by offering suggestions, references, and alerts during the clinical review process, improving efficiency and accuracy.
- Ensuring Clinical Documentation Improvement (CDI)
- AI-driven CDI tools enhanced the quality of clinical documentation, aiding nurses in providing comprehensive and accurate patient information for reviews.
- Allocating Resources Efficiently
The use of AI algorithms to optimize resource allocation identified high-priority cases, ensuring that codes and nurses assist where they are most needed.
Impact
Sagility helped the organization reduce friction around prior authorization operations, improving experiences across the care ecosystem.
Through the implementation of Generative AI solutions in coding and nursing reviews, Sagility also achieved measurable outcomes:
- 80% reduction in clinician administrative workload
- 50% boost in productivity and efficiency
- 96% accuracy with AI, improving compliance;100% accuracy with AI-assisted (hybrid) reviews
reduction in clinician administrative workload
Boost in productivity and efficiency
Accuracy with AI, improving compliance
Accuracy with AI-assisted
