Payers use nursing resources to perform health management activities. Yet payers face recruitment and retention challenges with a growing nursing shortage and rising demand for healthcare services. Artificial Intelligence (AI) in health management offers much-needed relief. It augments and integrates human ingenuity and clinical expertise with intelligent digital technologies. AI can take on many administrative tasks that nurses do now, allowing them to focus more time on functions that truly leverage their clinical expertise.

Because AI learns and consistently applies rules based on massive knowledge libraries, it improves the speed, consistency and quality of health management reviews. This is a win for nurses, payers, providers and members too. According to Accenture analysis, accelerating prior authorization and clinical review of claims is one of the top three areas that US health insurers can target to use AI-driven solutions to unlock up to $7 billion in total value in 18 months.

Feeling the pain

The decades-old nursing shortage is complicating health management staffing. Unfortunately, it will only get worse. The US Bureau of Labor and Statistics expects more than one million nursing vacancies by 2024.

This big squeeze on nursing supply could not happen at a worse time. Overall demand for medical services is increasing, which in turn drives increased health management demand. It is well documented that the nation’s aging population is putting pressure on the healthcare system. Medicare enrollment is expected to grow to 77 million by 2027, and per capita spending on healthcare among those 65 and older is two to three times higher than adults aged 19 to 64. This increase in utilization will drive additional demand for nursing staff to perform clinical reviews.

At the top of their license

Not only are there fewer nurses to take on rising demand, but some elements of the health management process are monotonous, creating inherent staffing challenges. Nurses are often saddled with administrative tasks, distancing them from the ability to apply their clinical expertise, and driving attrition for payers. The good news is that Accenture analysis of client experience shows that automation and AI can rebalance nurses’ workloads so they focus on tasks that are higher value and therefore drive job satisfaction (see Figure 1).

Rules-Based (Achieved)

20 percent of transactions have been automated with rules-based minibots and robotic process automation (RPA).

Rules-Based (Opportunity)

There is an additional 15 percent in rules-based areas of opportunity that may be considered for RPA.

Judgement Based

20 percent of judgement-based processes can be augmented by AI and analytics.

Experiential Knowledge Needed

45 percent of the remaining judgement work is being reviewed for AI. However, about 30 percent will require knowledge workers.

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A powerful combination

When automation and AI take on manual steps in clinical review—such as navigating between screens and systems or culling through case notes and pages of scanned medical documents—nurses can focus on medical necessity and care delivery data, dramatically improving throughput and quality.

It works like this. AI tools pre-read documents using clinical knowledge libraries with millions of associations to identify targeted opportunities and associated evidence. The information is presented to nurses in a consolidated view, so they can review the AI outputs, analyzing and interpreting the clinical content and how to support coordination of care. Ultimately, the nurses make the clinical decision, while the automation and AI plays a support role (see Figure 2). In addition, any data analyzed by the automation and AI tools is available for use throughout the payer organization.

A good news story

As payers apply these technologies to this new, more streamlined model, health management can become more efficient and consistent with faster and more accurate clinical review. This is a boon for provider and member satisfaction as well as for improved regulatory compliance. And when nurses have the time to focus on case management and care coordination, they can truly put their passion into practice.

Rick Stewart

Managing Director – Strategy & Consulting, Care Innovation Practice Lead

Brian Christian

Managing Director – Health, Payer Operations Lead

Theresa Gaffney

Managing Director – Health, Operations, Growth & Strategy


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