Payer Clinical Services
Transforming care delivery with advanced clinical solutions for payers.
Clinical Challenges
Health plans face growing clinical complexity as regulations such as HIPAA, CMS guidelines, and state mandates continue to evolve. At the same time, payers must enable interoperability across clinical and administrative systems, including HL7 and FHIR, while protecting sensitive member data across platforms and vendors.
Clinical workforce shortages add further strain. Gaps in qualified clinical talent can slow utilization management, care coordination, and quality reviews, increasing compliance risk, driving claim denials, and negatively affecting member outcomes, satisfaction, and Star Rating Managed Services.
Real Results. Real Impact.
With Sagility’s Payer Clinical Services, clients consistently see improved clinical performance and significant cost savings across their operations, including one or more of the following:
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reduced cost of clinical operations with intelligent automation
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improved productivity through automation and AI/ML tools
reduced administrative reviews and workflow
reduced price per authorization
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accuracy with AI assisted (Nurse Assist) reviews
Avoidance of long-term care
Explore Our Full Suite of Payer Clinical Services
Sagility Clinical Services help health plans deliver high-quality, cost-effective care through a combination of clinical expertise, advanced technology, and global delivery models. Our modular services optimize utilization management, care coordination, frailty and falls prevention, and claims denials while improving operational efficiency. Powered by AI, automation, and analytics, our clinical audits, regulatory reporting, and insights strengthen quality performance and support HEDIS and Star Ratings.
Utilization Management (UM)
Automate real-time clinical review and decisions on prior authorization with advanced UM and UM as a Service.
Care Management
Evidence-based service addresses common disease prevention for Medicare, Medicaid, and commercial payers and providers.
Sagility Smart Step
Our predictive frailty resilience and fall prevention program helps members stay healthy, independent, and out of the hospital.
Clinical Denials Management
Turn denials into opportunities. Our AI-enabled approach streamlines denial resolution, ensures accurate coding, and provides real-time analytics.
Prior Authorization
Extend your prior authorization team with U.S.-licensed offshore nurses and clinical reviewers who manage intake, review, and decisioning to improve speed and accuracy.
Star Rating Managed Services
Star Rating improvement service provides Medicare Advantage plans with guidance and end-to-end support through analytics, an expert team, and advanced technology.
Nurse Assist
GenAI- and agent-enabled clinical support reduces administrative burden and accelerates decision making. Nurse Assist helps clinicians and nurses summarize records, surface policy and criteria, standardize documentation, enabling faster authorizations while preserving human judgment.
Our Accreditations
Industry-recognized certifications that demonstrate our commitment to quality, security, and excellence.
Straight from the Source
We’re more than a vendor, we’re a partner. Here’s what our clients have to say:
Sagility invests time to understand our business and develops innovative solutions that would not be possible without their deep operational knowledge.
Payment Integrity Lead,
National Health Plan
They are technology-enabled but prioritize business and partner outcomes above all else. It is not about promoting tools for their own sake — Sagility thoughtfully applies a broad range of capabilities to deliver solutions that drive measurable results. They truly put the client first.
Executive Director, Business Operations,
Healthcare Financial Services Company
The implementation was seamless, and their support team is outstanding. We’ve achieved 98% accuracy in claims processing and reduced our days in A/R from 45 to 28. Their technology is truly game-changing for healthcare providers.
Revenue Cycle Director,
Multi-specialty physician group
Case Studies
See how we’ve helped payers unlock millions in savings and streamline operations:
Insights & Resources
Stay informed with the latest thinking on healthcare payer operations:
Ready to Work Smarter with Sagility?
Let’s explore innovative solutions tailored to your needs—and get more done, together.