Industries / Health Insurance

Payer, claims, clinical operations, member, provider, quality, risk adjustment, SIU, compliance, and data leaders

Health Insurance data + AI transformation

Health plans need to reduce administrative friction and improve member outcomes while protecting PHI, preserving clinical judgment, and operating within complex reimbursement and regulatory rules. Infinitive connects the systems you already run to trusted data and AI so teams can improve outcomes without separating innovation from governance.

Discuss Health Insurance priorities Explore use cases

Speak the language of the business

Start from the operating model—not the model.

Claims adjudicationPrior authorizationRisk adjustmentStars / qualityProvider networkUtilization managementFWAMember servicePHI

We use the language, measures, controls, and workflows your teams already operate, then connect them to modern data and AI capabilities.

Trusted Enterprise AI

Five capabilities. One business outcome.

Every use case can draw from the same Infinitive capability model: Data Foundations to enable AI; Analytics + Decision Support powered by AI; Governance + Risk to trust AI; Agents + Automation driven by AI; and Adoption + Workforce Enablement to realize value.

01Data FoundationsTo enable AI 02Analytics + Decision SupportPowered by AI 03Governance + RiskTo trust your AI 04Agents + AutomationDriven by AI 05Adoption + WorkforceTo realize the value of AI

Customer / constituent journey

Use AI where it improves the experience and the economics.

AI becomes more valuable when the same governed data and decision logic follows the journey instead of being rebuilt channel by channel.

Shop / enroll

Improve plan comparison, eligibility, enrollment support, and member education.

Access care

Help members navigate benefits, networks, referrals, and prior authorization requirements.

Receive care

Use claims and clinical signals to support care management, quality, and high-risk member outreach.

Resolve

Improve claims, appeals, grievances, explanations, and issue routing.

Manage health

Support preventive care, adherence, care gaps, and member engagement with appropriate human clinical oversight.

Renew

Understand experience, utilization, affordability, and retention drivers.

Employee journey

Give people better context, not another disconnected tool.

Infinitive redesigns the workflow so AI prepares evidence, finds patterns, and removes low-value effort while people stay accountable for judgment, exceptions, empathy, and business tradeoffs.

Member services

Gets a benefit-aware member summary, approved answers, and escalation guidance.

Claims / payment integrity

Uses AI to prioritize exceptions, summarize evidence, and detect patterns.

Clinical / UM team

Receives longitudinal context and guideline retrieval while retaining clinical decision authority.

Data / compliance

Govern PHI access, lineage, policy, model use, and evidence across workflows.

In-depth use cases

Where data, Databricks, and AI can change the work.

These are not generic AI demos. Each use case starts with a recognizable operating problem, the data required to solve it, the role of AI, the human decision point, and the measures that determine whether value is real.

Use case 01

Claims adjudication and payment integrity intelligence

Claims operations must distinguish clean claims, coding variation, contract rules, clinical context, and payment anomalies at high volume.

Trusted data on Databricks

Unify claims, eligibility, provider contracts, coding, clinical rules, prior authorization, payment, and adjustment history.

AI at work

Prioritize exceptions, explain likely causes, detect patterns, retrieve applicable rules, and assemble evidence for analyst review.

How Infinitive helps

Modernize claims data pipelines, create governed payment-integrity data products, implement AI review workflows, and measure recoveries and cycle time.

Human accountability

Claims and payment-integrity staff approve adjustments, recoupments, and provider communications.

Measures to improveAuto-adjudicationException cycle timePayment accuracyRecovery yieldProvider abrasion

Use case 02

Prior authorization workflow acceleration

Prior authorization involves benefit rules, clinical criteria, documentation completeness, provider communication, and time-sensitive decisions.

Trusted data on Databricks

Connect eligibility, benefit design, authorization history, clinical documentation, guidelines, provider data, and correspondence.

AI at work

Extract documentation, identify missing evidence, retrieve criteria, summarize the request, and route cases by complexity or urgency.

How Infinitive helps

Build the governed data and document layer, integrate utilization-management platforms, design review workflows, and monitor quality and timeliness.

Human accountability

Licensed clinical reviewers retain medical-necessity and exception decisions.

Measures to improveTurnaround timeIncomplete submissionsClinical reviewer capacityAppeal rateProvider experience

Use case 03

Member service and benefit intelligence

Members struggle to understand coverage, cost, network status, claims, and next steps, while service agents navigate multiple systems.

Trusted data on Databricks

Combine benefits, accumulators, claims, provider network, prior auth, interactions, documents, and approved knowledge.

AI at work

Prepare member context, retrieve plan-specific answers, explain claim status, summarize prior contacts, and route sensitive issues.

How Infinitive helps

Implement governed member context, retrieval, contact-center analytics, workflow integration, and adoption controls.

Human accountability

Agents retain responsibility for empathy, complex benefit interpretation, complaints, and escalation.

Measures to improveFirst-contact resolutionHandle timeRepeat contactsMember satisfactionEscalation quality

Use case 04

Risk adjustment and documentation intelligence

Risk-adjustment teams need accurate, supportable coding and documentation while avoiding unsupported inference or overreach.

Trusted data on Databricks

Connect claims, encounters, clinical documentation, provider data, chart-review status, coding guidance, and audit evidence.

AI at work

Prioritize records, retrieve evidence, summarize documentation, and flag coding opportunities or inconsistencies for qualified review.

How Infinitive helps

Build governed data products, document processing, workflow queues, audit trails, and monitoring.

Human accountability

Certified coders and clinicians validate documentation and final coding decisions.

Measures to improveChart-review productivityEvidence completenessCoding accuracyAudit response timeDocumentation quality

Use case 05

Provider network and quality intelligence

Network leaders balance access, cost, quality, performance, capacity, and geographic coverage across thousands of providers.

Trusted data on Databricks

Unify provider directories, claims, quality, access, contract, credential, member, and geographic data.

AI at work

Identify network gaps, provider anomalies, quality trends, referral patterns, and capacity constraints; summarize root causes for action.

How Infinitive helps

Build network data products, geospatial analytics, decision-support experiences, and governed metrics.

Human accountability

Network and clinical leaders approve contracting, remediation, and member-impact decisions.

Measures to improveDirectory accuracyAccess gapsQuality performanceNetwork costProvider-management efficiency

Use case 06

Fraud, waste, and abuse investigation support

SIU teams investigate complex relationships across claims, providers, members, codes, locations, referrals, and prior cases.

Trusted data on Databricks

Bring claims, provider, member, referral, payment, geospatial, case, and external data into governed investigation-ready structures.

AI at work

Surface anomalous patterns, related entities, recurring schemes, case summaries, and evidence paths for investigator review.

How Infinitive helps

Design the investigation data model, graph and anomaly analytics, AI workspaces, and case integration with auditability.

Human accountability

SIU investigators determine case disposition, referrals, and external reporting.

Measures to improveCase prioritizationInvestigation cycle timeEvidence qualityRecovery opportunityRepeat-pattern detection

How Infinitive engages

Land with a focused need. Expand through demonstrated value.

Clients can enter at any stage. We do not require a multi-year transformation before value is visible; we connect the right capabilities to the immediate problem and scale only where the evidence supports it.

01Activate

Define a priority problem, establish trusted data, and demonstrate value through a focused engagement or POC.

02Productionize

Make the capability secure, reliable, governed, measurable, and useful in everyday operations.

03Scale

Extend proven value across teams, workflows, data domains, and business areas—only where evidence supports it.

Why Infinitive

Trust is part of the architecture and the operating model.

Infinitive combines data and AI delivery with governance, risk, transformation, and adoption so the same team can address the technical path and the organizational conditions that determine whether AI actually works in practice.

Build on enterprise reality

Connect core systems, controls, teams, and existing investments rather than designing a disconnected AI island.

Govern at design time

Data access, lineage, security, policy, auditability, cost, and human decision rights are defined before production.

Prove value before scale

Use a focused entry point with business measures so the next decision is based on evidence—not enthusiasm.

Keep people accountable

AI can automate preparation and pattern finding; people remain at judgment, exception, empathy, and accountability.

Health Insurance next step

Choose one workflow where better data and AI could change the outcome.

Bring the business owner, data/platform lead, and operating or risk leader. Infinitive will help frame the use case, required data, governance needs, human decision points, and the right Activate, Productionize, or Scale path.

Request a working session Why Infinitive