Introduction: The Moment That Shapes Everything
In workers’ compensation, the first 24 hours after a workplace injury are not just about filing a claim. They represent a critical window in which clarity, coordination, and compassion determine what happens next.
Will care be delayed or delivered on time? Will the worker feel supported or left in the dark? Will mistakes multiply, or will the process be set on the right track?
The answers to these questions depend largely on one overlooked but powerful process: claims triage.
What Is Claims Triage?
Claims triage refers to the early, structured process of sorting and prioritizing claims based on risk factors, complexity, urgency, and other key variables. It is similar to what happens in an emergency room: professionals assess which cases need immediate attention, which can wait, and which follow a standard path.
In workers’ compensation, effective triage means:
- Identifying red flags early
- Directing resources where they are needed most
- Avoiding unnecessary delays, duplications, and costs
When done properly, triage sets the foundation for faster recovery, better documentation, and fewer disputes.
Why It Matters in the First 24 Hours
Research and real-world experience confirm what many industry professionals already know: what happens in the first day sets the tone for everything that follows. The earlier we identify a risk, intervene to support a worker, or clarify a point of confusion, the fewer problems we face later.
Missed or mishandled triage in the first 24 hours can lead to:
- Delayed medical care
- Escalated legal costs
- Preventable disputes
- Long-term disability claims
- Compromised trust between stakeholders
On the other hand, strong triage supports:
- Faster treatment and resolution
- More accurate documentation
- Better return-to-work planning
- Lower overall claim costs
How AI + HI™ Powers Better Decisions
Artificial intelligence (AI) enhances traditional triage by using data to detect risks and opportunities that might not be obvious to a human reviewer. Human intelligence (HI), on the other hand, provides the ethical compass, real-world context, and relationship-based insight that machines cannot replicate.
Together, AI + HI™ means:
- AI scans thousands of historical claims to detect patterns and make predictions
- HI applies judgment, empathy, and nuance to guide the right response
- Both work in harmony to avoid oversights and protect fairness
This is not about automating people out of the process. It is about empowering professionals to make faster, better-informed decisions while maintaining the human touch.
Triage Tools You Can Use
CLARA Triage by CLARA Analytics: Offers predictive analytics for adjusters to flag high-risk claims early.
Function: Offers predictive analytics for claims adjusters to flag high-risk claims early.
How to Use It Effectively:
- Review the dashboard daily: High-risk claim alerts may be subtle, reviewing your triage dashboard each morning ensures nothing slips through.
- Pair alerts with human outreach: If a claim is flagged as high-risk, do not just document it, call the injured worker or provider immediately to clarify details and assess barriers.
- Document your reasoning: Even when the AI flags a claim, human rationale is critical. Always include a short note on how the data influenced (or did not influence) your next step.
TMP Tip: Use CLARA’s insights not only to sort claims, but also to train new adjusters on spotting warning signs.
Gradient AI: Delivers performance analytics and AI-powered scoring for TPAs and program managers.
Function: Provides TPAs and program managers with AI-powered risk scoring, performance analytics, and predictive cost modeling.
How to Use It Effectively:
- Set thresholds for alerts: Use built-in settings to customize what qualifies as “high risk” for your organization’s metrics. This reduces noise and improves focus.
- Spot patterns, not just outliers: Gradient AI excels at identifying system-level risks, trends in location, job class, or treatment delays that can help redesign safety protocols.
- Integrate data into executive reports: Use visual dashboards to inform leadership of claim trends and cost drivers.
TMP Tip: Do not treat Gradient AI as a static report, it is a dynamic tool for root-cause analysis and proactive planning.
Origami Risk: Supports employers with automated reporting workflows and compliance tracking.
Function: Assists employers and supervisors with automated incident reporting, intake tracking, and compliance workflows.
How to Use It Effectively:
- Train supervisors on proper data entry: The value of automated workflows depends on the quality of initial input, ensure consistent terminology and prompt submission.
- Activate compliance reminders: Origami can flag missing forms or late actions. Set up alerts to stay ahead of audit risks.
- Connect with modified duty tracking: Employers using Origami can pair triage data with return-to-work monitoring, ensuring care decisions align with operational needs.
TMP Tip: Encourage frontline managers to use Origami not just for compliance, but also as a communication tool that helps keep HR, safety, and claims in sync.
Tools Are Only as Smart as the People Using Them
Each of these AI platforms, CLARA, Gradient AI, and Origami Risk, offers a different lens into the triage process. But none of them replaces human judgment. Their greatest value comes when trained professionals interpret the alerts, ask the right follow-up questions, and act with integrity.
In the AI + HI™ model, tools bring speed and structure, while people bring context and compassion.
Insight from The MedLegal Professor™
“Claims triage is not just a technical process. It is the first ethical decision point in a case. When AI + HI™ work together, we do not just save time. We protect people, prevent harm, and fulfill the promise of the workers’ compensation system.”
Join me for our monthly AI + HI™ Masterclass Webinar Series, where we explore:
- Real-world claims triage examples
- Step-by-step use of beginner-friendly AI tools
- How to embed fairness and foresight into early workflows
The MedLegal Professor’s Insight™: The first 24 hours are not a checklist. They are a test of our system’s integrity. AI + HI™ helps us pass that test, not only by speeding up the process, but by ensuring that behind every data point is a person who deserves to be seen, heard, and supported.
Let Us Reimagine the First 24 Hours, Together
