AI-Powered Claims, Pharmacy & Clinical Analytics
Score every claimant and employer group 0–100 in seconds; not quarterly review cycles.
RiskFlow's scoring engine ingests paid claims, pharmacy fills, and clinical context, then runs a weighted risk model to produce a transparent 0–100 Stop-Loss Exposure Score for every member and a portfolio roll-up for every employer. Scores refresh the moment new claims land, so account managers triage tomorrow's $250K claimant today.
Each member gets a 0–100 exposure score tied to claims velocity, diagnosis category, pharmacy mix, and decade-of-life risk. Score appears inline on the claimant card.
Individual scores aggregate into an employer risk score with tier distribution (low / moderate / elevated / critical) and projected renewal impact.
The model flags sudden claim spike deltas against the trailing 90-day baseline so newly-accelerating claimants surface before the deductible is breached.
Projected year-end claims are computed per claimant against the specific deductible and aggregate corridor; renewal risk score forecast on a 12-month horizon.
Monthly 837/835 files via secure SFTP or API. Members match to existing exposure records by de-identified ID.
Engine scores each member on claims velocity, diagnosis category, pharmacy mix, and historical burn against deductible.
Member scores roll up into portfolio-level risk tiers and renewal increase percentage per employer group.
Scores, trends, and projected renewal impact light up the executive command center and claimant registry.
“We flagged a $380K claimant six weeks before our carrier did. That single score paid for three years of RiskFlow.”