AI-Enhanced Insurance Claims Workbench
Intelligent Process Flow Map & Technical Specifications
Version 1.0 | July 22, 2025
📋 Table of Contents
🎯 Executive Summary
This document outlines the enhanced Claims Workbench system that integrates AI agents strategically throughout the insurance claims processing workflow. Building upon the existing SharePoint-based infrastructure, this enhancement maintains human oversight for critical decisions while automating routine tasks to achieve significant efficiency gains.
75%
Reduction in manual data entry
50%
Faster claim processing times
90%
Improvement in compliance checking
24/7
Automated initial processing
🚀 Phase 1: Intelligent Claim Intake & Initial Processing
1
Smart Claim Reception
Current Process
- Email sent to Claims Shared Mailbox
- Manual ticket creation and data entry
- Manual categorization by claim type
- Manual field population
AI-Enhanced Process
AI Email Processing Agent
- Continuously monitors shared mailbox 24/7
- Automatically extracts key information (policy numbers, claim types)
- Auto-categorizes by product type (Funeral, Group Life, Credit Life, Health)
- Creates tickets with pre-populated data fields
- Identifies trigger events (Natural Death, Accidental Death, Suicide, etc.)
Value: 80% reduction in manual data entry, 24/7 processing capability, improved data accuracy and consistency
2
Intelligent Source Validation
Current Process
- Manual validation of claim source
- Manual policy holder verification
- Basic fraud checking
AI-Enhanced Process
AI Validation Agent
- Cross-references OWLS and SQL Claims systems automatically
- Validates policy holder information against multiple databases
- Flags suspicious patterns or potential fraud indicators
- Auto-assigns risk scores and priority levels
- Integrates with Master Policy and intermediary databases
Value: Faster validation process, early fraud detection, consistent risk assessment across all claim types
⚡ Phase 2: Smart Assignment & Processing
3
Intelligent Assignment
Current Process
- Manual assignment to representatives
- Basic availability checking
- Limited expertise matching
AI-Enhanced Process
AI Assignment Agent
- Analyzes claim complexity, handler workload, and expertise
- Routes claims based on specialization (funeral, health, accident specialists)
- Balances workload considering user limits and capacity
- Factors in SLA requirements and handler availability
- Optimizes for best assessor/approver matching
Value: Optimal resource allocation, reduced processing time, improved expertise matching for better outcomes
4
AI-Assisted Claim Processing
Current Process
- Rep manually updates claims and uploads documentation
- Manual subtask creation
- Manual trigger event selection
- Manual status tracking
AI-Enhanced Process
AI Document Processing Agent
AI Task Generation Agent
AI Subtask Creation Agent
- OCR and NLP processing of medical reports, death certificates, police reports
- Auto-populates claim fields from extracted document data
- Generates subtasks with unique numbering (e.g., 123-1, 123-2, 123-3)
- Suggests tasks based on product type and trigger events
- Tracks productivity per product, group, and trigger event automatically
Value: 60% faster document processing, consistent subtask creation, automated tracking and reporting
✅ Phase 3: Intelligent Validation & Review
5
Smart Task Validation
Current Process
- Manual validation of task completion
- Manual checking of documentation requirements
- Manual compliance verification
AI-Enhanced Process
AI Compliance Agent
- Validates required documentation by trigger event and product type
- Checks Master Policy requirements and data sufficiency
- Ensures regulatory compliance for each product category
- Flags missing information and generates follow-up tasks
- Cross-references OWLS and SQL Claims system requirements
Value: Improved compliance, reduced regulatory risk, consistent validation standards across all products
6
AI-Powered Claim Assessment
Current Process
- Manual claim value validation
- Manual sign-off assignment
- Basic comparisons
AI-Enhanced Process
AI Assessment Agent
- Analyzes claim value against historical data by product and trigger event
- Compares similar claims for consistency and anomaly detection
- Flags outliers for human review and investigation
- Suggests appropriate sign-off levels based on value and risk
- Integrates productivity tracking across all dimensions
Value: Consistent assessments, faster processing of standard claims, improved accuracy and fraud detection
💰 Phase 4: Enhanced Payment Processing
7
Intelligent Payment Queue Management
Current Process
- Manual status update to "Ready for Payment"
- Manual payment queue management
- Basic duplicate checking
AI-Enhanced Process
AI Payment Orchestration Agent
- Automatically validates all task completion requirements
- Performs comprehensive duplicate payment checking
- Routes high-value payments for additional supervisory approval
- Optimizes payment batching for efficiency
- Schedules payments based on cash flow management
Value: Reduced payment errors, optimized cash flow, enhanced fraud prevention, improved audit trails
8
Smart Payment Validation
Current Process
- Manual payment task validation
- Manual beneficiary verification
- Basic audit trail creation
AI-Enhanced Process
AI Payment Validation Agent
- Performs final compliance and regulatory checks
- Validates beneficiary details against policy information
- Cross-checks payment amounts with approved claim values
- Monitors for suspicious payment patterns or anomalies
- Auto-generates comprehensive audit trails with timestamps
- Links payment records to original ticket and subtask numbers
Value: Enhanced security, improved audit capability, reduced manual validation time, comprehensive traceability
📊 Phase 5: Intelligent Monitoring & Analytics
9
Predictive Analytics & Insights
Current Process
- Manual reporting and reactive management
- Basic dashboard viewing
- Limited trend analysis
AI-Enhanced Process
AI Analytics Agent
- Continuously monitors claim patterns across all product types
- Predicts potential SLA breaches and resource bottlenecks
- Analyzes productivity per product, per group, per trigger event
- Identifies process improvement opportunities based on historical data
- Generates real-time dashboards for all user levels
- Provides TV dashboards for team self-monitoring
Value: Proactive management, continuous optimization, data-driven decisions, predictive resource planning
10
Smart Communication Management
Current Process
- Manual customer communication and status updates
- Template-based email responses
- Manual handling of status requests
AI-Enhanced Process
AI Communication Agent
- Generates personalized status updates based on claim progress
- Sends proactive notifications at key milestones
- Handles routine customer inquiries about claim status automatically
- Manages multi-claim status requests with automated table generation
- Escalates complex queries to appropriate human agents
- Maintains communication history linked to tickets and subtasks
Value: Improved customer satisfaction, reduced manual communication overhead, consistent messaging
🤖 AI Agent Technical Specifications
Email Processing Agent
Function: Automated email monitoring and ticket creation
Technology: NLP, Email parsing APIs, SharePoint REST API
Integration: Exchange Online, SharePoint Lists, ThinkAutomation
Monitors shared mailboxes 24/7, extracts claim information, and creates structured tickets with pre-populated fields based on email content analysis.
Validation Agent
Function: Policy verification and fraud detection
Technology: Database connectors, Pattern recognition algorithms
Integration: OWLS system, SQL Claims database, External policy databases
Cross-references multiple systems to validate policy information and detect potential fraud patterns using advanced analytics.
Assignment Agent
Function: Intelligent workload distribution
Technology: Machine learning algorithms, Load balancing
Integration: User management system, Skills matrix, SLA monitoring
Optimizes claim assignment based on handler expertise, current workload, and claim complexity for maximum efficiency.
Document Processing Agent
Function: OCR and document data extraction
Technology: Computer Vision, Azure Cognitive Services, NLP
Integration: SharePoint document libraries, Form processing pipelines
Processes various document types including medical reports, death certificates, and invoices to extract relevant claim data.
Task Generation Agent
Function: Automated task and subtask creation
Technology: Rule engines, Process automation, Template systems
Integration: Claims workflow, Regulatory compliance databases
Creates appropriate tasks and subtasks based on claim type, trigger events, and regulatory requirements with unique numbering.
Compliance Agent
Function: Regulatory compliance monitoring
Technology: Rule engines, Compliance checking algorithms
Integration: Regulatory databases, Audit systems
Ensures all claims meet regulatory requirements for each product type and trigger event, flagging compliance issues.
Assessment Agent
Function: Claim value analysis and risk assessment
Technology: Statistical analysis, Historical data modeling
Integration: Claims database, Historical claims data
Analyzes claim values against historical patterns to identify outliers and suggest appropriate approval levels.
Payment Orchestration Agent
Function: Payment workflow automation
Technology: Workflow engines, Payment validation systems
Integration: Payment systems, Banking APIs
Manages the entire payment workflow from validation to execution, including duplicate checking and fraud prevention.
Analytics Agent
Function: Predictive analytics and reporting
Technology: Machine learning, Data visualization, Power BI
Integration: SharePoint analytics, Business intelligence tools
Provides comprehensive analytics and predictive insights across all aspects of the claims process for strategic decision-making.
📈 Expected Benefits & ROI
Quantitative Benefits
75%
Reduction in manual data entry tasks
50%
Faster claim processing times
90%
Improvement in compliance checking accuracy
60%
Reduction in processing errors
40%
Improvement in customer satisfaction scores
30%
Reduction in operational costs
Qualitative Benefits
- Enhanced fraud detection capabilities through advanced pattern recognition
- Improved regulatory compliance with automated checking and validation
- Better resource allocation and workload management across teams
- Consistent claim assessment standards across all product types
- 24/7 automated processing capability for initial claim handling
- Scalable system architecture that grows with business needs
- Improved employee satisfaction through reduced repetitive tasks
- Enhanced audit trails and compliance reporting capabilities
🗺️ Implementation Roadmap
Phase 1: Foundation (Months 1-3)
- Deploy Email Processing Agent
- Implement Validation Agent
- Establish AI-SharePoint integration framework
- Set up basic analytics infrastructure
- Train initial user groups
Phase 2: Core Processing (Months 4-6)
- Deploy Assignment Agent
- Implement Document Processing Agent
- Launch Task Generation Agent
- Integrate Compliance validation
- Expand user training and adoption
Phase 3: Advanced Features (Months 7-9)
- Deploy Assessment Agent
- Implement Payment Orchestration Agent
- Launch Advanced Analytics Agent
- Implement predictive capabilities
- Optimize system performance
Phase 4: Optimization (Months 10-12)
- Deploy Communication Agent
- Fine-tune all AI models
- Implement advanced fraud detection
- Complete system optimization
- Full deployment and monitoring
👥 Enhanced User Access Levels with AI Integration
Claims Handler (Enhanced)
- Access to AI-assisted document processing
- AI-generated task recommendations
- Smart form auto-completion
- Intelligent claim routing notifications
- Enhanced productivity tracking
Claims Payment Handler (Enhanced)
- AI-powered payment validation tools
- Automated fraud detection alerts
- Smart payment batching recommendations
- Enhanced audit trail generation
- Real-time compliance checking
Supervisor (Enhanced)
- AI-driven workload distribution tools
- Predictive SLA monitoring
- Team performance analytics
- Automated escalation management
- Advanced reporting capabilities
Management (Enhanced)
- Advanced AI analytics dashboards
- Predictive business intelligence
- Process optimization recommendations
- Strategic decision support tools
- ROI and performance metrics
Administrator (Enhanced)
- AI agent configuration and monitoring
- Advanced user analytics
- System optimization tools
- AI model performance tracking
- Security and compliance management
⚙️ Technology Stack & Integration
AI Platform Components
- Azure Cognitive Services for OCR, NLP, and document processing
- Power Automate for workflow orchestration and AI integration
- Azure Machine Learning for predictive analytics and model training
- Power BI for enhanced dashboards and business intelligence
- Azure Functions for serverless AI processing
Existing System Integration
- SharePoint Online (existing foundation and UI)
- OWLS Claims System integration via APIs
- SQL Claims Database connectivity and synchronization
- ThinkAutomation for enhanced email processing
- jQuery/JavaScript framework (existing responsive UI)
- REST API architecture (existing integration layer)
📊 Success Metrics & KPIs
Operational Metrics
- Average claim processing time
- First-time resolution rate
- SLA compliance percentage
- Error rate reduction
AI Performance Metrics
- Document processing accuracy
- Fraud detection rate
- Prediction accuracy
- Automation success rate
Business Impact Metrics
- Cost per claim processed
- Revenue cycle time
- Customer satisfaction scores
- Employee productivity gains
👤 Human Oversight Framework
Critical Human Oversight Maintained For:
- Final claim approval decisions - High-value or complex claims requiring judgment
- Complex fraud investigation - Suspicious claims requiring detailed investigation
- High-value payment authorization - Payments above defined threshold limits
- Customer escalation handling - Complex customer service issues and complaints
- Policy interpretation - Ambiguous policy coverage decisions
- Legal and regulatory decisions - Complex compliance and legal matters
- Quality assurance oversight - AI decision validation and model improvement