Use case
Use case3 min readBy The Data Workers Team

Utilization management data, run by agents

Authorization, claims and clinical data arrive from different systems and timestamps disagree, so turnaround and approval metrics are argued about. Here is how Data Workers runs it instead.

Key takeaways

  • •The problem today. Authorization, claims and clinical data arrive from different systems and timestamps disagree, so turnaround and approval metrics are argued about.
  • •What changes. Agents unify auth, claims and clinical events with governed definitions of turnaround and approval, and keep them fresh for reporting.
  • •What stays with your people. Regulatory UM reports: they are filed with regulators.
  • •The result. UM metrics agree across operations, clinical and compliance.

The problem today

Authorization, claims and clinical data arrive from different systems and timestamps disagree, so turnaround and approval metrics are argued about.

What changes with Data Workers

Agents unify auth, claims and clinical events with governed definitions of turnaround and approval, and keep them fresh for reporting.

The workflow: Connectors agent (get_connector_status) → Data Context & Catalog agent (define_business_rule) → Quality Monitoring agent (set_sla) → Autonomous Data-Conductor (verify_data).
Fig. 1:The workflow: Connectors agent (get_connector_status) → Data Context & Catalog agent (define_business_rule) → Quality Monitoring agent (set_sla) → Autonomous Data-Conductor (verify_data).

The workflow, step by step

  1. 1.The Connectors agent calls get_connector_status and lands auth and clinical feeds.
  2. 2.The Data Context & Catalog agent calls define_business_rule and defines turnaround and approval.
  3. 3.The Quality Monitoring agent calls set_sla and tracks feed freshness.
  4. 4.The Autonomous Data-Conductor calls verify_data and verifies regulatory reports.

The impact metrics we move

  • •Turnaround report: from about a week to ~1 h
  • •Auth feed issue traced: from about 2 days to 15-20 min
  • •Definition question: from about a day to seconds
Time to complete, current practice (black) vs. with Data Workers (green). Illustrative.
Fig. 2:Time to complete, current practice (black) vs. with Data Workers (green). Illustrative.

What goes on autopilot

  • •Turnaround and approval rates are computed from governed definitions, so teams stop arguing about timestamps.
  • •Auth and clinical feeds run on freshness SLAs, so reports are current.

Where your people stay in charge

Regulatory UM reports always go to a named approver, because they are filed with regulators. Everything starts at L1, observing only, and autonomy rises only on evidence.

The pilot

  • •Scope. Governed turnaround metrics for one program.
  • •First week. Agents run at L1, observing only, and show the fixes they would have made, with receipts.
  • •By week two. The routine work above runs on its own; anything sensitive stays with a named approver.
  • •At day 30. We review the impact metrics against your baseline:
  • •Turnaround report: from about a week to ~1 h
  • •Auth feed issue traced: from about 2 days to 15-20 min
  • •Definition question: from about a day to seconds
  • •Cost. Start with a pilot ($7,500 one-time, credited in full against the first year). Scale is from $1,000 a month and Enterprise from $3,000 a month, billed annually, with unlimited seats, no usage meter and no markup on model spend. See pricing.

Related: The health plans and payors hub · The full team playbook

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