Optimize Risk Adjustment Performance with AI & Analytics

  • December 04, 2018
  • 1:30 PM – 2:30 PM ET
  • Online

In today’s risk adjustment landscape, the adoption of technology to generate analytics and direct operational resources is the base level of automation required for health insurance providers to compete in a world of increasing data volumes, growing memberships, and intricate provider networks. Standard tools and approaches are not keeping pace with demands and new ways to apply innovation are needed to be successful.

With ambitions to scale its membership and create better relationships with its affiliated physicians, Chinese Community Health Plan (CCHP) sought a more comprehensive and holistic path to optimizing its risk adjustment performance through the utilization of Natural Language Processing (NLP); a subcategory of Artificial Intelligence (AI).

Two years into leveraging NLP-enabled technology, CCHP has realized several retrospective review performance improvements, including year-over-year MA revenue gains, an 80 percent decrease in document reviews, and improved efficiencies across chart chase. Bolstered by these wins, CCHP has expanded its use of NLP into suspecting analytics and targeted physician education outreach, a program they initiated across MA and ACA member populations. Consequently, CCHP is now able to:

  • Code ahead of schedule, usually about 3+ months in advance.
  • Focus their chart chase efforts.
  • Identify additional unsubstantiated codes.
  • Track, measure, and report on physician gap closure using analytics


Jean Rao
Manager of Pharmacy and Health management

Jean is the manager of pharmacy and health management at CCHP, and oversees the pharmacy and risk adjustment teams. Prior to joining CCHP, Jean was a managed care pharmacy resident at OmedaRx, a national pharmacy benefit manager focused on evidence-based medicine. She received her Pharm.D. from the University of California, San Francisco, with a focus in Health Sciences and Policy Research.

Mariana Kwok
Risk Adjustment Supervisor

Ana is the Risk Adjustment Supervisor at CCHP and is responsible for managing performance improvement projects including planning, monitoring, and implementation of risk adjustment initiatives and physician incentive programs. Ana Kwok obtained her bachelor’s degree in Psychology at San Francisco State University.