Medical Prior Authorization
Faster Approvals. Less Admin. Better Care.
Autonomize's Prior Authorization Workflow reduces review time by 50%, with clinical intelligence from day one. Purpose-built for healthcare, it integrates into existing systems to drive faster decisions, fewer delays, and stronger compliance—using embedded clinical appropriateness and medical necessity guidelines, as well as internal criteria.
- 55% reduction in review time
- Decision turnaround time cut by half
- Up to 76% of cases auto-intaked with human oversight
- 18 minutes saved per case—reclaiming up to 36,000 hours monthly
Pharmacy Prior Authorization
Less Manual Work. Shorter Cycle Times. Faster Decisions for Providers and Patients.
Health plans and PBMs running pharmacy PA manually are losing time at every step. Autonomize unifies ingestion, normalization, clinical criteria evaluation, and real-time decision support into one governed agentic workflow.
- 98% accuracy in clinical data abstraction
- 95% accuracy in clinical contextualization
- 90% auto-approval rate
- 85% of users report meaningful time savings
Appeals & Grievances
Faster Resolutions. Defensible Outcomes.
The Appeals & Grievances Workflow reads, structures, and summarizes case data, ensuring complete documentation and alignment with CMS and state mandates.
- 70% cut in prep effort per case
- 93% accuracy in document extraction
- 50% faster turnaround across case types
Care Management
Less Documentation. Real-Time Visibility. More Time for Members.
Care managers shouldn't spend 45 minutes per member chasing data across fragmented systems. This workflow synthesizes it for them, auto-generating compliant, structured care plans with real-time visibility into member risk and gaps.
- 78% reduction in documentation time
- 150,000+ care plans generated annually per enterprise
- Real-time risk and care gap visibility
- Compliance-aligned to CMS, NCQA, and Medicaid requirements
Letters & Correspondence
Fewer Templates. Less IT. Faster, Compliant Communications.
Managing thousands of compliance templates across lines of business shouldn't require an IT ticket. Autonomize automates template creation and maintenance, with multilingual support and compliance alignment built in.
- 70-80% reduction in templates and related IT requests
- 60%+ improvement in staff productivity
- 40-60% compliance risk reduction
- ROI in 90 days versus a typical two-year timeline
Fraud, Waste, and Abuse
Prevent Improper Payments. Protect Revenue. Reduce SIU Burden.
Most plans are still catching fraud after the fact, recovering only a fraction of what's lost. Autonomize shifts that equation by embedding AI-led intelligence upstream, across both provider submission and health plan pre-payment review, before improper claims are ever paid.
- FW&A represents an estimated $1.3T in annual healthcare spend exposure
- 15% of claims are denied, with 80% preventable upstream
- 10% of claims are fraudulent, with only 50% recovered post-payment
- Humans retain legal and escalation authority throughout
Claims Processing
Fewer Errors. Faster Adjudication. Cleaner Claims.
Autonomize’s workflow structures and validates claim attachments and notes at intake. It enforces policy rules, boosts accuracy, and lowers downstream appeals.
- 55% reduction in adjudication cycle time
- Strong ROI within 12 months
- Fewer disputes and escalations
Risk Adjustment
Fewer Missed Codes. Less Manual Review. Better Revenue Accuracy.
Missed HCC codes and unreliable RAF scores cost plans revenue and compliance standing. Autonomize's Risk Adjustment workflow proactively detects missed conditions, validates documentation, and surfaces coding opportunities before they slip through.
- 15-25% increase in verified and supported RAF yield
- 40-60% reduction in manual chart review
- 50% decrease in retrospective vendor spend
- ROI realized in 90-120 days
Care Gaps Review
Close Gaps Sooner. Improve Quality Scores.
Built to identify gaps with HEDIS/STAR precision, this workflow links EMRs, claims, and clinical notes into one clear view—so enterprises intervene sooner and meet performance goals.
- 85% automation of gap detection
- 95%+ alignment to HEDIS/STAR
- Shorter outreach cycles, stronger scores
Clinical Audits for UM/CM/A&G
Full Coverage. Faster Reviews. Consistent Oversight.
Random sampling leaves too much on the table. Autonomize's Clinical Audits workflow standardizes audit criteria, flags exceptions automatically, and scales coverage to 100% across Utilization Management (UM), Care Management (CM), and Appeals & Grievances (A&G) without adding headcount.
- 100% audit coverage across UM, CM, and A&G, replacing random sampling
- 30-50% faster review cycles
- 2-3x scalable audit capacity without adding headcount
- Built-in alignment to regulatory and organizational guidelines
Eligibility Verification
Instant Coverage Answers. Less Call Volume. Fewer Claims Delays.
Every unanswered coverage question creates downstream friction, in claims, in appeals, in member trust. Autonomize consolidates plan data across systems to deliver instant answers on coverage and cost for members and providers alike.
- 2.5M cases handled across all lines of business
- 85K+ requests processed per month at scale
- 60%+ extraction accuracy for HEDIS measures
- Reduces redundant lookups, claims rework, and member abrasion
Complex Document Processing
From Document Chaos to Structured Clarity
This workflow uses Compound AI to categorize, structure, and route documents rapidly and accurately.
- 98%+ accuracy in clinical data abstraction
- 93%+ precision in document extraction
- 80% manual workload reduction
- 50% faster intake-to-decision time
Intake, Extraction, and Case Creation
Less Manual Entry. Fewer Errors. Faster Time to Decision.
When intake teams spend 35 to 90 minutes per case re-keying data from faxes and PDFs, everything downstream slows down. This workflow converts unstructured inputs into structured, actionable cases using an agentic approach that eliminates redundant steps entirely.
- 94% fully automated intake for faxes and incoming requests
- 98%+ accuracy in clinical data abstraction
- 93%+ precision in document extraction
- 50-75% manual workload reduction