Processes

Perform research and resolve inquiries

How perform research and resolve inquiries are reshaped as AGI capability advances.

ProcessesPerform research and resolve inquiries
Perform research and resolve inquiries — illustrated

Business-as-Code

Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.

Perform research and resolve inquiries sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Perform research and resolve inquiries inherits.

Where Perform research and resolve inquiries sits

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How the work flows

Trigger: A member, provider, or broker submits a complex question, grievance, or appeal that requires escalation beyond tier-one support.

  1. Log and classify the escalated inquiry or appeal
  2. Assign the case to a dedicated research specialist
  3. Extract policy terms, medical records, and historical claims data
  4. Evaluate the collected data against coverage guidelines and state regulations
  5. Determine the appropriate resolution or claims adjustment
  6. Update the policy administration and claims systems
  7. Draft and send the final determination notice to the stakeholder

Outcome: The inquiry is investigated, a definitive resolution is applied to the account, and the stakeholder is notified of the outcome.

Measured by

Average Resolution TimeInquiry Backlog VolumeResolution Accuracy RateAppeals Overturned Rate