Overview of the Clinical Intelligence Engine
The Clinical Intelligence Engine is the decisioning foundation of the Medecision Platform. It combines real-time data ingestion, rules processing, risk stratification, and AI-powered insight delivery to drive intelligent workflow automation and member engagement.
How It Works
The engine orchestrates dynamic workflows by evaluating a combination of medical, behavioral, and social data inputs in real time. It outputs intelligent decisions—such as task assignments, campaign targeting, or outreach escalation—into care management, utilization management, and digital engagement applications.
Builder Tool Suite
Medecision's builder tools are self-service, no-code/low-code interfaces that empower clinical, operational, and business users to configure automation logic, campaigns, and workflows without developer support.
These builders work together across the Medecision Platform to:
Reduce manual effort and clinical burden
Personalize care journeys and engagement
Improve timeliness and compliance
Drive real-time responsiveness to data events
Rules Builder
The Rules Builder creates real-time, event-based logic to drive workflow triggers, decisioning, and automation. It executes real-time rules based on new data, such as ADTs, claims, and labs. The rules can trigger workflows, send notifications, assign risk scores, and launch campaigns.
The Rules Builder features the following capabilities:
IF/THEN rules with nested logic and operators
Event-driven triggers from claims, ADTs, assessments, and more
Dynamic task generation and routing
Support for eligibility checks, risk scoring, alerting, and reassignments
Rule versioning, simulation, and approval workflows
Population Builder
The Population Builder defines dynamic cohorts of members or providers for program eligibility, targeting, or reporting. It segments members based on clinical, behavioral, or demographic criteria, and it supports nested logic, inclusion/exclusion rules, and scheduled re-evaluations.
The Population Builder features the following capabilities:
Filters members using diagnosis, utilization, demographics, and engagement history
Support for rule-based and schedule-based refresh
Assigns populations to programs, campaigns, or stratification bands
Ability to be exported and audited
Program Builder
The Program Builder designs configurable care programs with defined logic, phases, and outcomes. It defines which workflows, tasks, and assessments are triggered for specific populations, and it supports eligibility windows, recurrence, and auto-close criteria.
The Program Builder features the following capabilities:
Defines program entry/exit criteria
Links to workflows, assessments, and campaigns
Auto-closes or escalates based on inactivity or criteria
Triggers stratification rules, tasks, or outreach steps
Campaign Builder
The Campaign Builder deploys targeted, data-driven member outreach via SMS, email, and portal notifications. It includes multi-channel outreach for nudging, education, reminders, or screening follow-up. Available channels include email, SMS, in-app message, and chatbot integration.
The Campaign Builder features the following capabilities:
Drag-and-drop visual campaign designer
Campaign triggers based on clinical events or stratification
Multi-channel sequencing with fallback logic
Message templates with personalization support
Template Builder
The Template Builder creates reusable content templates for campaigns, letters, and digital messaging. It features the following capabilities:
Support for merge tags, branding, and variables
Multi-language content management
Versioned templates for compliance and reusability
Journey Builder
The Journey Builder defines longitudinal guided health journeys for members with complex engagement flows. It includes bi-directional logic to drive interactive care experiences with conditional branching. It supports surveys, educational content, task creation, and pause/resume logic.
The Journey Builder features the following capabilities:
Combines messages, assessments, and tasks over time
Pauses/Resumes based on configured logic and conditional routing
Triggers journeys from programs, risk events, or outreach
Assessment Builder
The Assessment Builder builds clinical and non-clinical assessments to support eligibility, risk, and documentation. It features the following capabilities:
Conditional branching and dynamic scoring
Assigns assessments to programs or tasks
Auto-triggers follow-ups or escalates based on responses
Exports to clinical documents or dashboards
AI Agent Builder
The AI Agent Builder builds Build task-specific or omnichannel generative AI agents using platform data. It features the following capabilities:
Automates intake, summarization, triage, and response
Integrates with Google Gemini or other LLMs
Governs prompts and source content
Used for internal staff tools or external portals
Medical Policy Codifier
The Medical Policy Codifier manages and digitizes medical necessity policies for automated review and prior authorization. It features the following capabilities:
Codifies clinical rules tied to CPT/ICD codes
Applies logic to incoming requests
Triggers correspondence or escalation
Includes full version control and traceability for audits
AI and ML Integration
Available integration of artificial intelligence and machine learning provides models for likelihood to approve, likelihood to engage, and likelihood to close. This is used in Guided Intake, Outreach Prioritization, and Fax Routing. Models are continuously trained using labeled request history and interaction logs.
Personalization and Targeting
The Clinical Intelligence Engine features dynamic triggering, which executes rules based on timestamped events or relative timelines (e.g., “3 days post-discharge”). Also incorporated are behavioral triggers like reminder frequency, channel preference, and timing optimization. AI outputs include rationale, attribution scores, and approval risk indicators.
Monitoring and Governance
All rule executions are logged and time-stamped for audit and debugging. Builder permissions are controlled by user role (for example, rule editor, publisher) and builder users can be assigned per domain (for example, CM, A\&G, Outreach). The Clinical Intelligence Engine also includes a Test Mode that allows for simulation of rule execution before publishing to production.
All builders feature role-based access controls
Changes are logged with full audit trail
Most support draft, review, and publish lifecycle