Proactive Healthcare Coverage Risk Analysis System
Implements a 9-phase agentic workflow with autonomous decision-making capabilities. Uses Holt-Winters forecasting, multi-employer hour aggregation, and proactive alert generation to prevent coverage loss.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
Coverage analysis input screen with quick start templates, member information form, hours data tracking, and AI agent pipeline visualization
Agent orchestration theater displaying real-time multi-agent workflow execution with inter-agent communication, tool invocations, and overall progress tracking
Coverage analysis results showing risk assessment scores, days to action, people affected, monthly savings projections, and COBRA cost comparisons
Detailed risk assessment view with probability of coverage loss, risk factors, protective factors, SHAP-like feature contributions, and AI reasoning chain
AI Agents
Specialized autonomous agents working in coordination
Multi-Employer Intelligence Agent
Union members work across multiple contributing employers, making it difficult to aggregate total hours for eligibility determination and identify reciprocity opportunities.
Core Logic
Aggregates hours from all contributing employers in real-time, applies reciprocity rules for cross-fund transfers, identifies hour banking opportunities, calculates combined eligibility status, and tracks employer contribution patterns for reliability scoring.
Risk Assessment Agent
Identifying members at risk of coverage loss requires analyzing complex patterns in work hours, employer reliability, seasonal variations, and historical coverage gaps.
Core Logic
Applies logistic regression model with 8 risk factors to calculate Probability of Coverage Loss (PCL). Analyzes rolling 3-month hours against 360-hour threshold, evaluates employer count and volatility, generates risk scores with Wilson confidence intervals, and identifies protective factors.
Forecasting Agent
Predicting future work hours and eligibility status requires sophisticated time series analysis accounting for seasonality, trends, and employer-specific patterns.
Core Logic
Implements Triple Exponential Smoothing (Holt-Winters) for 90-day coverage forecasts. Decomposes time series into level, trend, and seasonal components, calculates MAPE accuracy metrics, projects daily hour accumulation, and identifies critical eligibility threshold crossing dates.
Family Impact Analysis Agent
Coverage loss affects entire families differently based on dependent health needs, ages, and healthcare utilization patterns requiring personalized impact assessments.
Core Logic
Calculates family vulnerability scores based on dependent count, ages, and chronic conditions. Models COBRA cost burden against household income, identifies at-risk dependents with ongoing treatment needs, generates family-specific intervention recommendations.
Agent Collaboration Coordinator
Multiple specialized agents may produce conflicting assessments requiring structured consensus-building to reach reliable conclusions.
Core Logic
Facilitates cross-validation between Risk Assessment, Forecasting, and Family Impact agents. Implements confidence-weighted consensus voting, resolves discrepancies through evidence comparison, and produces unified analysis with documented reasoning chains.
Recommendation Agent
Generating actionable recommendations requires synthesizing risk assessments, forecasts, family impact, and available intervention options into prioritized action plans.
Core Logic
Produces prioritized intervention recommendations with urgency levels. Calculates optimal intervention timing, estimates success probability for each option, generates personalized member communications, and schedules automated follow-up actions.
Proactive Alert Agent
Members and administrators need timely warnings about impending coverage issues before they become critical, delivered through appropriate channels.
Core Logic
Generates smart alerts based on configurable triggers: PCL thresholds, days-to-termination, hour shortfalls, and family vulnerability scores. Determines optimal communication channels (email, SMS, portal), schedules outreach windows, and tracks alert acknowledgment.
Autonomous Decision Agent
Routine coverage interventions require human approval creating delays. Low-risk decisions could be automated while maintaining appropriate oversight.
Core Logic
Implements autonomous decision authority within defined guardrails. Auto-approves low-risk actions (notifications, hour banking), escalates high-impact decisions with recommendation, maintains complete audit trail, and supports human override at any point.
Validation & Compliance Agent
All coverage decisions and communications must comply with ERISA notice requirements, COBRA regulations, and plan document provisions.
Core Logic
Validates recommendations against plan document rules, ensures COBRA notice timing compliance, verifies ERISA disclosure requirements, checks 2025 regulatory updates, and generates compliant member communications with required legal language.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
5 technologies
Architecture Diagram
System flow visualization