How a Leading Health Plan Reduced Administrative Burden and Expanded Member-Facing Capacity

Overview

A leading health plan partnered with Autonomize AI to transform prior authorization (PA) intake operations and redirect valuable staff capacity from administrative processing to work that more directly supports members.

The organization wanted to improve responsiveness, accelerate care decisions, and strengthen the member experience, particularly for seniors and other vulnerable populations with complex healthcare needs. Achieving those goals required reducing the amount of time clinical and operational teams spent reviewing documents, entering data, and routing requests.

By automating data extraction, classification, and intelligent routing, the health plan transformed a labor-intensive intake workflow into a scalable, largely autonomous operation. The result was not simply greater efficiency. It gave the organization the capacity to redeploy experienced employees to member and provider support, care management, outreach, and other activities with a more direct impact on access, experience, and outcomes.

The Challenge

The health plan’s Utilization Management team relied on a fully manual process for handling prior authorization requests received by fax. Each request required an employee to:

• Open and review the submitted documents
• Extract clinical and administrative information
• Consult the financial responsibility grid
• Determine the appropriate destination
• Route the request to an internal clinical team or delegated medical group

As volumes increased, the process became increasingly difficult to sustain. The intake queue had grown to more than 15,000 faxes, requiring six full-time employees dedicated solely to intake activities.

Nurses and care management staff were spending as much as 40% of their time on administrative work instead of clinical decision-making and member support. Valuable staff capacity was being consumed by repetitive document review, data entry, and routing tasks.

This limited the organization’s ability to direct resources toward activities that required human judgment and personal engagement, such as helping members navigate care, responding to provider questions, resolving complex cases, conducting outreach, and supporting members with chronic or complex conditions.

For the health plan, the challenge was not simply to process prior authorizations faster. It was to create the operational capacity needed to serve members more effectively without continually adding administrative staff.

The Solution

Autonomize deployed its AI-powered Utilization Management Prior Authorization Solution, integrating directly with the organization’s existing fax infrastructure and care management platform.

The solution automatically processes incoming faxes and extracts essential clinical and administrative information, including:

• Member and provider details
• Diagnosis and procedure codes
• Service type
• Dates of service
• Supporting clinical documentation

It then classifies each request, applies the organization’s routing logic, and directs the case to the appropriate internal team or delegated medical group before employee intervention is required. Requests that require additional review can be directed to the appropriate staff member, allowing employees to focus on exceptions and complex cases rather than manually processing every fax.

The implementation was completed in just 90 days without disrupting existing clinical workflows.

Results and Business Impact

Since deployment, the organization has seen substantial improvement in overall efficiency, including:

• 86% automated routing rate
• 40% reduction in processing time
• More than 100 staff hours per week recovered
• Reduction in intake staffing needs from 6 FTEs to 2
• 51% reduction in the fax queue backlog

With AI managing routine intake activities, four team members were redeployed to higher-value work, including:

• Providing more direct support to members and providers
• Resolving a Part B audit backlog
• Staffing a new care management process that previously lacked sufficient resources
• Supporting complex cases requiring human judgment and coordination

This allowed the health plan to shift capacity away from administrative processing and toward activities that improve the member experience. Instead of spending their days opening faxes and entering information, employees could spend more time answering questions, resolving barriers to care, coordinating services, and helping members navigate the healthcare system.

What’s Next

The prior authorization intake deployment represents the first phase of a broader enterprise automation strategy with Autonomize. Building on this success, the organization is expanding automation across additional clinical, member-facing, and administrative workflows, including:

• Extending automation to additional Utilization Management intake channels
• Automating Grievances and Appeals workflows
• Supporting Care Management workflow automation
• Deploying AI voice agents for member outreach

Together, these initiatives are creating a more efficient and scalable operating model. Routine administrative work can be managed through AI-enabled workflows, while employees are redeployed to the work that benefits most from human expertise: engaging members, addressing complex needs, coordinating care, and improving health outcomes.