RAG-Powered

Streamlining Claims Processing with RAG-Powered SOP Decision Trees

A healthcare and insurance organization needed to simplify complex claims processing workflows governed by extensive Standard Operating Procedures (SOPs). The goal was to improve processing speed, ensure consistent decision-making, and reduce manual interpretation of policy guidelines.

Objectives

Claims processors relied on lengthy SOP documents to determine the correct course of action, resulting in inconsistent decisions, slower turnaround times, and increased operational complexity. Business users also struggled to interpret complex policy logic without technical support. The client aimed to:

  • Standardize claims processing across teams.
  • Reduce delays caused by manual SOP interpretation.
  • Improve decision accuracy and regulatory compliance.
  • Enable faster onboarding of business users with guided workflows.

Solutions​

EX Squared transformed complex SOP documents into structured, searchable knowledge using Retrieval-Augmented Generation (RAG). The solution dynamically generated decision trees that guided users through every stage of the claims process.

At each decision point, users could ask context-aware questions and receive accurate, source-backed responses based on the relevant SOP content. This intelligent workflow simplified policy interpretation, standardized decision-making, and made complex claims processes easier for business teams to navigate.

Results

With AI-guided decision support in place, claims teams processed cases faster and more consistently while reducing manual effort.

Faster and more consistent claims processing.

Reduced manual errors and improved compliance.

Standardized decision-making across teams.

Simplified interpretation of complex SOPs for business users.

Increased operational efficiency through AI-guided workflows.

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Let us know how we can help shape your future.

Sahil Dhawan​​

General Manager, India

Leading our international development and data science teams Sahil leads a team of over 200 highly skilled senior technologists. creating an award Winning culture has resulted in a team that delivers a level of excellence unmatched by our global competitors.

JW

Head of Design

With digital product design leadership and experience forged at great brands like Capital One, Intuit and Match®, among others, JW brings the deep experience our clients demand in order to launch award winning digital products that delight and amaze users.

Steve Darnell​​

Chief Financial Officer​

Steve Darnell is a strategic financial executive with deep experience in driving fiscal performance, operational efficiency, and long-term value creation. As CFO at EX Squared, he leads financial planning and analysis, capital strategy, and risk management while partnering across teams to align financial goals with company growth. Steve brings a data-driven mindset and a strong foundation in corporate finance, helping steer the organization through key investment decisions and scalable business initiatives.

Johanna Fernandez​

General Manager, LATAM

With over 15 years of experience in human resources and business administration, Johanna brings unique insights into stakeholder & conflict management, driven by my commitment to human development. As a licensed Practitioner of NLP and certified in Management 3.0, she is dedicated to creating collaborative environments and driving business success through effective management, conflict resolution, negotiation, and process improvement. Additionally, Johanna is a fierce advocate for women's equity in the tech industry, striving to break barriers and foster diversity and inclusion.

Mike Peloquin​​

VP

It's not every day you get to work with amazingly talented people. I'm thrilled to say I do. They're not just the people who work here at EXSQ; they're the people we collaborate with at our clients. Together we form brilliant digital product ideas into innovative enterprise-scale digital products for some of the world's best brands. We set the highest standards, we work damn hard and we have a blast doing it.

Lisa Carolan​

VP, Delivery and Operations​

Lisa brings energy and innovation to analyze needs and define technology solutions to meet our customer goals. Her experience spans recognizable brands including HP, Sony, Lennar Homes, SLB, and Bank of America along with startup and growth phase organizations.

With two decades of experience spanning major brands like HP, Sony, Lennar Homes, and Bank of America, as well as startups, Lisa excels at driving results-focused strategies that align with client goals. Her expertise in designing and implementing technology has helped organizations innovate and scale, ensuring measurable engagement and outcomes that drive mutual success.

Krishna Murthy

Chief Executive Officer

With a proven track record in helping businesses navigate the digital disruption occurring around them, his background is solidly founded in digital transformation. Under his leadership, EXSQ has grown into a premier technology partner, serving clients large and small. Krishna’s management philosophy is based on the principle of servant leadership and putting our clients first in all we do here at EXSQ, and he has set the benchmarks for how we hire and retain the finest talent possible, fostering a culture of excellence at EXSQ.

Krishna’s expertise spans technology leadership, eCommerce and SaaS development, mergers and acquisitions, and global business operations. He has notable experience in strategic planning, investor relations, and board-level interactions. With experience across companies at varying stages of maturity, Krishna also leads initiatives in data science, AI, analytics, and talent development, ensuring EXSQ remains at the forefront of innovation and operational excellence.

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