Workflows
18 decisions · 17 governed
3
MS
Active (6)
Completed (19)
Templates
New Workflow
Status: All
Type: All
Assigned to: All
Date range: Last 7 days
In Progress
Complex Claim Adjudication — Member M-8832, Cardiac Rehab Extension
Claim Adjudication
High Complexity
Started 9 Aug, 09:15 · Triggered by claims reviewer referral
Step 4 of 6 · Benefit verification & policy cross-reference
MS
Maria Santos
3 of 4 checkpoints
Open →
In Progress
Post-Discharge Care Transition — Member M-5541
Care Transition
High Priority
Started 7 Aug, 10:00 · Triggered by discharge notification from Valley Medical
Step 3 of 5 · Outreach & coordination
DP
David Park
2 of 3
Open →
In Progress
Utilization Review — Cardiac Rehabilitation Program
Utilization Review
Quarterly
Started 8 Aug, 08:00 · Triggered by automated schedule + utilization threshold alert
Step 3 of 5 · Variance driver analysis
AP
Dr. Aisha Patel
2 of 3
Open →
Awaiting Review
Care Gap Batch Analysis — Q3 Cohort
Care Gap Analysis
Routine
Started 9 Aug, 06:00 · Automated quarterly schedule
Complete — 47 members identified, outreach list ready for coordinator review
DP
David Park
4 of 4
Open →
Not Started
Prior Authorization Review — Member M-6614, CAR-T Therapy
Prior Auth
Urgent
Due 10 Aug 2026 · Referred by claims reviewer
Queued — requires medical director initiation
AP
Dr. Aisha Patel
—
Open →
Not Started
Clinical Policy Assessment — GLP-1 Coverage Criteria
Policy Review
Medium Priority
Due 16 Aug 2026 · Triggered by AMA guideline update
Queued — awaiting medical director schedule
AP
Dr. Aisha Patel
—
Open →