Ai Innovation Strategy For Promise Health Plan: A Framework For Equitable Medi-Cal Transformation

Abstract

California's Medi-Cal program serves over 14 million vulnerable beneficiaries suffering from chronic care gaps, operational inefficiency, and health inequalities. Through three linked domains—governance and regulatory compliance, predictive population health management, and smart administrative automation—this essay offers a complete artificial intelligence plan for Blue Shield Promise Health Plan aimed at resolving these issues. While deploying machine learning algorithms trained on Facets claims data, electronic health records, and social determinants of health to pinpoint high-risk members and avoid unnecessary hospitalizations, the framework forms an AI Governance Council overseeing model fairness, explainability, and DHCS-HIPAA-CMS compliance. Natural language processing and generative AI automate claims adjudication, prior authorization, and HEDIS abstraction, targeting notable improvements in administrative cost reduction and processing efficiency. With secure ingestion pipelines, feature stores, model registries, and real-time governance monitoring, the technical architecture combines modern data platforms with legacy systems. This model sets standards for artificial intelligence deployment in Medi-Cal managed care companies throughout while promoting value-based care delivery for safety-net groups.

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