This document outlines validated, production-ready use cases that can be implemented using Medecision’s workflow applications, data platform, and builder tools. These use cases reflect real-world implementations across health plans, delegated entities, and provider organizations.

Tools Used: Population Builder, Program Builder, Rules Builder\ Overview: Automatically identify high-risk members based on claims or SDOH data and enroll them into appropriate programs.

Tools Used: Rules Builder, Clinical Intelligence Engine\ Overview: When a member has an inpatient or ED admit, trigger tasks and assign outreach to care team within seconds.

Tools Used: Assessment Builder, Journey Builder\ Overview: Deliver health risk assessments to eligible members with automated follow-ups and real-time scoring.

Tools Used: Campaign Builder, Template Builder\ Overview: Identify unengaged members in programs and send SMS/email nudges to reinitiate contact.

Tools Used: Intake UI, Rules Builder, Medical Policy Codifier\ Overview: Provide immediate validation and medical necessity feedback as providers submit prior auth requests.

Tools Used: AI/ML Builder, Rules Builder\ Overview: Use AI predictions to automatically approve high-likelihood, low-risk requests without human review.

Tools Used: TAT Rule Builder, Dashboards\ Overview: Track turnaround time per CMS requirement, auto-escalate nearing deadlines, and notify management.

Tools Used: Correspondence Builder, Intake Portal\ Overview: Accept digital appeal submissions, auto-route based on plan type, and confirm receipt.

Tools Used: Correspondence Builder, Rules Builder\ Overview: Trigger member letters based on case status change or appeal resolution outcome.

Tools Used: Campaign Builder, Population Builder\ Overview: Define cohort (e.g., seniors without flu shot) and deploy SMS/email reminders with scheduling options.

Tools Used: Journey Builder, Campaign Builder\ Overview: Detect stalled care journeys and send multi-step outreach sequence to reconnect.

Tools Used: Rules Builder, Real-Time Feed\ Overview: Evaluate complex risk logic in real time when member is admitted or discharged.

Tools Used: Analytics Feed, Dashboards\ Overview: Measure downstream impact of engagement (e.g., increase in completed assessments or visits post-campaign).

Tools Used: Medecision FHIR APIs\ Overview: Allow downstream systems or provider EMRs to query real-time member, coverage, and case data.

Tools Used: Ingestion Engine, Assessment Builder\ Overview: Ingest externally completed screenings (e.g., PHQ-9) and reflect in CM/UM workflow tasks.