Claims Verification and Risk Scoring
Verify Claims and Assess Risks in a Streamlined, Data-Driven Way
Description
Introduction:
Many claims management processes are inefficient due to a lack of prioritization and risk assessment. Our Claim Verification and Risk Scoring Module addresses this by automatically identifying potential risk areas in claims and assigning scores to prioritize claims management.
Overview:
The Claim Verification and Risk Scoring Module checks claim data against established rules and assigns risk scores based on potential fraud, waste, or abuse. High-risk claims are flagged for further review, helping claims assessors prioritize their work and improve claim accuracy. It allows for customizable scoring parameters and if it can integrate with external fraud databases or third-party sources to improve verification accuracy. This module increases efficiency and reduces fraud-related delays.
Benefits:
This module helps streamline the claims process by ensuring that assessors focus their efforts on high-risk claims, improving the efficiency of fraud detection and reducing potential processing delays. It helps maintain claims integrity by prioritizing claims that need further review.
Resources
Features
The Claim Verification and Risk Scoring Module leverages AI to verify claims against preset rules, assigning risk scores that prioritize high-risk claims for review. This helps reduce fraud-related delays and streamline claims processing for assessors.
Features and Capabilities:
Rule-Based Claim Verification: Ensures claims meet established rules before advancing through the process.
Risk Scoring Algorithm: Assigns risk scores to claims based on likelihood of fraud, waste, or abuse.
Automated Flagging System: Flags high-risk claims for further review by assessors. Priority Workflow Management: Prioritizes flagged claims for manual investigation or further scrutiny.
Customizable Risk Criteria: Allows the adjustment of risk thresholds for different claim types.
Integration with Claims System: Seamlessly integrates with existing claims management workflows.
Real-Time Risk Monitoring: Continuously tracks and scores claims as they enter the system.
Key Information
Platform Modules:
Neutrinos Predictive AI Hub: Deploy and manage predictive models to enable real-time, data-driven decisions across rules, case management & workflows.
Version: 24.09
Neutrinos Case Automation Workbench: Empowering teams with an intelligent, automated workspace for efficient case management and decision support, integrated within the ecosystem.
Version: 24.03
Neutrinos Business Rules Engine: Empower your processes with intelligent, real-time decision automation at scale. Accelerate decision-making and policy enforcement with intuitive rule automation.
Version: 24.07
Neutrinos Observability 360: Turn data into insights, empower strategic decisions with real-time business metrics and actionable insights creating impactful decisions.
Version: 24.05
Neutrinos Microservices and Integration Foundry: Effortlessly connect and scale your services with an integrated microservices and API management and configurator.
Version: 23.11
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