AI EMPLOYEES
Modernize utilization management with agentic AI
Automate medical necessity reviews, improve consistency, and ensure compliance with CMS utilization management reforms.
Utilization Management (Payers)
Healthcare Payers
154
Running
85%
Automated UM cases
Why utilization management is under fire
Inconsistent clinical decisions
Traditional UM processes rely on subjective review and fragmented data.
30–60 minutes per case spent on manual clinical review
Compliance and transparency risk
CMS and state regulators are demanding transparent UM workflows and documentation.
25% of denials overturned due to documentation errors
Operational inefficiency
Each review takes hours and requires multiple staff—costs rise while turnaround times slip.
1–4 reviewers touch each case before final determination
Automate key steps of utilization management
Pre-service review
AI employees analyze clinical documentation, compare against coverage criteria, and recommend determinations with supporting rationale.
Monitor inpatient stays and automatically surface medical necessity checkpoints as documentation arrives.
Detect improper payments and streamline peer review by pre-assembling evidence packets.
Generate compliant audit logs for CMS, NCQA, and state UM reporting automatically.
1) Intake and classification
AI employees read inbound UM requests, extract structured data, and classify them by service type and urgency.
Transform UM outcomes
85%
Automated UM cases
Reduce manual review workload with consistent, explainable AI-driven decisions.
2–3 weeks
Typical time to go live
Deploy fast without heavy integrations or technical support.
100%
Audit-ready transparency
Every action is logged for compliance and internal QA review.
90%
Reliability end-to-end
Reduce operational costs while improving provider experience.
What healthcare payers are saying
“Before Magical, UM decisions were inconsistent across reviewers. Now every case follows the same criteria and audit trail—our appeal rate is down 40%.”
“Our clinical reviewers love it—Magical handles the routine cases, so they can focus on high-acuity reviews. Productivity and morale have never been higher.”
Security & compliance
HIPAA compliant
Magical processes all data locally with zero PHI storage
SOC 2 Type II certified
Enterprise-grade security with regular third-party audits
Secure Authentication
Single Sign-On (SSO) and multi-factor authentication options
See how agentic AI modernizes UM
How does AI handle clinical reviews?
AI employees evaluate structured and unstructured data using rule sets and criteria libraries, escalating ambiguous cases to licensed reviewers.
Does it meet NCQA and CMS UM requirements?
Yes—each workflow maintains timestamped audit trails and adheres to federal and state UM standards.
What systems does it integrate with?
Compatible with HealthEdge, Cognizant QNXT, and custom UM platforms via API or UI automation.
Can reviewers override AI recommendations?
Yes—AI employees provide explainable recommendations; human reviewers retain full decision authority.
How long to implement?
Average deployment time is 2–4 weeks depending on scope and data access.
