Operationalize Smarter Insights

Leverage cutting-edge machine learning and artificial intelligence solutions for next-generation healthcare.

Data Science

As the healthcare ecosystem changes and evolves with new technology and new market entrants, it is important for healthcare organizations, both health plans and providers, to generate more insight from their data and make smarter decisions about member care, revenue management, contracting and costs. Edifecs Smart Decisions, which includes our Artificial Intelligence and Machine Learning solutions, can help you achieve those mission-critical insights.

Our Solutions

Edifecs Smart Decisions combines the fundamental building blocks required to derive quantifiable value from healthcare data into a single solution approach. This approach includes a platform of tools integrated into a common data store as well as machine learning algorithms designed by data scientists with a deep understanding of the healthcare domain.

Smart Decisions

  • Machine Learning, Deep Learning and Artificial Intelligence
  • Machine Learning Workbench
  • Data Set Management
  • Algorithm Management

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ML App Store

  • Expanding library of Machine Learning/AI solutions for specific business questions.
  • Improve medication adherence of members with adherence prediction and intervention recommendation
  • Predictive identification and remedy of claims payment problems
  • Opioid Abuse Management:  Identify members, providers and pharmacies with an increased risk for opioid abuse.
  • Member engagement and satisfaction Improvement
  • Disease and cost prediction for members
  • Machine learning driven member, provider and claim matching algorithms

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Who We Help

Health Plans

Edifecs enables health plans to bring the power of AI and Machine Learning to their core operational processes.  Claim and encounter processing, care management, provider management and pharmacy management all benefit from increased efficiency and effectiveness of AI enhancement.

State Medicaid Agencies

Edifecs can assist State Medicaid Agencies by bringing Machine and Deep Learning to their Population Health efforts as well as abuse monitoring programs.


Edifecs can help providers improve revenue by enhancing their claims payment process, decreasing rework and denial percentages and reducing administrative costs.  The Smart Decisions platform can also better target “at risk” patients and close gaps in care.

Pharmacy Benefit Managers

PBMs need an effective means to bridge the gap between pharmacy and medical data to improve their members’ health and identify fraud, waste and abuse.  Edifecs solutions support this integration as well as provide Machine Learning solutions to drive even greater value.