PHM Clinical Navigator

Population HealthAsync jobs required

Risk-tier members, detect care gaps, match care-management programs, and sequence next-best actions.

Population healthRisk tieringCare gapsCare managementTCM/CCM

About

A population-health navigator. For each member it computes a risk tier (RAF plus recent utilization), detects HEDIS care gaps, matches eligible care-management programs (CCM, PCM, TCM, BHI, rehab, DSMES, rare-disease routing) with their billing anchors, identifies rare-disease routing needs, and sequences a next-best-action plan.

An optional LLM narrative explains the plan per member, and a care-plan audit validates each recommendation against the member's profile, downgrading anything unsupported to review.

How it works

  1. 1Member roster (demographics, ICD codes, encounters, programs) + as_of date
  2. 2Deterministic risk tier + chronic-condition + care-gap detection
  3. 3Program eligibility matching (e.g. TCM within the 14-day post-discharge window)
  4. 4Optional LLM narrative + care-plan audit

Intended use

  • •Care-management panel prioritization by risk tier
  • •Transitional-care (TCM) and chronic-care (CCM / PCM) program enrollment
  • •Rare-disease center-of-excellence routing

Key outputs

  • ▸Per member — risk_tier, care_gaps, matched programs (with billing anchors), sequenced actions
  • ▸Narrative (optional) and care-plan audit verdicts
  • ▸/programs — the program catalog with eligibility rules + reference versions

Endpoints

Try each endpoint with your signed-in session — usage counts toward your monthly budget.

Use synthetic data only. Do not submit real patient records or PHI when testing endpoints.

Limitations & caveats

  • –Roster is capped at 200 members per request
  • –Recommendations are care-coordination support, not clinical orders
  • –narrative / audit add LLM stages (~60–90s); set both false for instant deterministic plans