Overview

Medecision Risk Management is a cloud-delivered SaaS solution built for health plans, health systems, and risk-bearing healthcare organizations. The platform leverages advanced analytics and AI to accurately calculate HCC risk scores, identify uncaptured diagnoses, and improve risk stratification and coding compliance. It helps clinical, coding, and care management teams streamline chart review, recapture missing codes, and support provider collaboration to ensure members receive appropriate care while optimizing reimbursement accuracy.

Features and Capabilities

• Core Risk Scoring & Coding:
  • Advanced HCC risk models for accurate severity assessment and stratification.
  • Calculates CMS-aligned risk scores and highlights coding opportunities.
  • Enhances reimbursement precision by detecting uncaptured diagnoses.
• Workflow Tools & Productivity:
  • Role-based risk adjustment worklists to focus on high-impact members.
  • Integrated chart audit support via clinical summaries from EMRs.
  • Missing code recapture to recover supplemental revenue opportunities.
  • Suspect code recommendations to support clinician decision-making.
  • Point-of-care collaboration interface for real-time coding and documentation insights.
• Operational Intelligence:
  • AI-driven precision identifies clinical gaps and population risk trends.
  • Intelligent dashboards to share risk insight with provider teams.
• Agent-Led Capabilities:
  • Additional AI agents deliver insights such as Care Plan Recommendation.
  • Program Advisors to guide population health program optimization.
  • Automated document and prior authorization review support.
  • Gap Closure tools to proactively improve quality and compliance.