Use Case 1
Monthly Gap Reconciliation
Trigger: Payer gap file received
1.Ingest payer gap list
2.Scan EHR structured data for closure evidence
3.Run NLP against clinical notes, imaging, specialist reports
4.Mark gaps as closed with citation
5.Calculate remaining open gaps
6.Prioritize by HEDIS weight and patient risk tier
7.Route to closure pathway (data-push, outreach, provider, care manager)
✓
Care teams work a clean prioritized list, not a bloated payer file full of already-closed gaps.
Use Case 2
Pre-Reporting HEDIS Sprint
Trigger: 90 days before HEDIS reporting deadline
1.Identify measures below Star-rating thresholds
2.Calculate members needed to close per measure
3.Rank by tier-movement probability
4.Assign to closure pathways with aggressive SLAs
5.Monitor daily burn-down
✓
Targeted, math-backed HEDIS push lifts Star ratings before the reporting window closes.
Integrations
Payer Quality/Gap Platforms (Stars, HEDIS)
EHR / FHIR R4
HIE / Specialty Notes
Pharmacy Claims Feed
NCQA HEDIS Specifications
Industries
healthcare
See It In Action
A sample conversation with this agent
Reconcile this month's payer gap list against our EHR.
Loading payer gap file: 4,312 open gaps across 2,847 attributed members. Cross-referencing against EHR structured data, clinical notes, imaging records, and specialty reports. Running now. Early results show ~35% are already closed—mostly colonoscopy and mammogram records that exist in our specialist notes but never made it back to the payer. I'll produce a clean list of truly open gaps, prioritized by HEDIS weight and patient risk tier.
What are my highest-impact gaps to close before year-end?
Top 5 by Star rating impact: (1) Controlling Blood Pressure — 312 members, triple-weighted measure, currently at 68% vs. 4-Star threshold of 76%. (2) Diabetes A1c Control — 287 members, double-weighted, 3 percentage points from next tier. (3) Medication Adherence for Diabetes — 198 members, triple-weighted. (4) Breast Cancer Screening — 164 members. (5) Colorectal Cancer Screening — 143 members. Closing just the top two would move us up a full Star.
Which of these need chart review vs. outreach?
Splitting the pipeline: 612 gaps have clinical evidence of closure already in the chart but weren't captured in structured data—these need chart-review and data-push to payer, no patient contact required. 1,847 need patient outreach (scheduling, reminders, at-home kits). 234 need provider intervention (med adjustment, order entry). 91 are complex cases requiring care manager review. I'm routing each pathway automatically once you approve the plan.