Case Advisor SaaS Flashcards
What is Optum’s Case Advisor and what does it do?
Optum Case Advisor is a cloud-based clinical decision support platform for hospitals’ utilization management. It uses AI and evidence-based criteria to help determine the appropriate patient status (e.g. inpatient vs. outpatient) and streamline the utilization review process . In short, it’s a standalone tool that analyzes patient records and provides recommendations (with supporting evidence) to guide care level decisions.
How does Case Advisor leverage artificial intelligence in utilization review?
Case Advisor employs advanced AI, including deep learning and natural language processing (NLP). It was trained on millions of past case reviews to recognize patterns that indicate medical necessity . The AI sorts and scores cases by likelihood of needing inpatient care  and extracts key facts from patient records, linking them to relevant medical research. This allows it to prioritize critical cases, auto-screen routine ones, and present clinicians with important details and citations in seconds.
In what way does Case Advisor assist with inpatient vs. outpatient (observation) determinations?
It provides guidance on patient status by analyzing each case and indicating the probability that inpatient admission is warranted. For borderline cases (e.g. a short hospital stay), Case Advisor will highlight risk factors and criteria that support inpatient admission or suggest observation status. Essentially, it flags high-risk cases that likely need inpatient level of care and ensures that any inpatient decision is backed by appropriate clinical evidence, helping staff make the correct call on admission status .
What are the core benefits of using Optum Case Advisor for a hospital?
Case Advisor offers several key benefits:
• Improved efficiency: It automates and accelerates chart reviews, allowing staff to handle more cases with less effort . By prioritizing which cases to review in depth, it saves nurses and physicians time and reduces administrative burden.
• Enhanced accuracy & consistency: Decisions on patient status become more consistent and evidence-based, as the AI applies the same criteria to every case and catches details humans might miss.
• Stronger revenue integrity: With better initial decisions and fully documented justifications, hospitals see fewer payer denials and can defend their admissions more effectively . This means more compliant, defensible documentation and protection of reimbursement.
• Optimized resource use: Case Advisor helps ensure that inpatient beds are used for patients who truly need that level of care while others are managed appropriately as outpatients, thereby reducing unnecessary hospital days and associated costs.
What distinguishes Case Advisor from traditional utilization management tools or criteria sets?
Unlike static criteria manuals or basic rule engines, Case Advisor is an interactive, AI-driven workflow tool. Its distinguishing features include:
• AI-Powered Insights: It doesn’t just list criteria – it actively reads patient data and interprets it using AI models (LLMs and NLP).
• Real-Time EHR Integration: Case Advisor pulls data directly from patient records and updates recommendations dynamically, functioning within the hospital’s workflow rather than offline.
• Evidence Citations: It automatically provides citations to medical literature and guidelines alongside its recommendations, which is unique in making each decision backed by published evidence .
• Comprehensive Workflow Support: The platform supports the full UM process (triage, first-level review, second-level review, documentation for payers) in one system. This end-to-end support and its AI capabilities set Case Advisor apart as a next-generation UM solution.
