Proposed addition · new act

Six roles, six journey maps: phases, actions, thinking, and the emotion each one rides.

Standard journey-map anatomy — a lens (who, what scenario, what goal), phases left to right, what they do and think in each one, and a single emotion line plotted across the whole thing. Built from every screen across all three prototypes, cross-checked against the case study's own copy.

Found while checking for contradictions

The console's roster mislabels T. Reyes. Screen A's reviewer table lists her as RN / Clinical. Every screen she actually opens (D1, D2) identifies her as special investigations, bill‑side. Treated here as a labelling bug in the roster table, not a second Reyes.
“One claim, 5127, followed end to end” isn't true of the built screens. The case study's own copy claims one continuous claim across the analyst's desk and the member's phone. The screens don't agree with each other: the analyst's claim 5127 is Wilma Traoré's SNF stay (screens B1/B2); the member's letter is Marisol's Bayshore billing case — a different person, a different story, sharing a number by accident. Told below as the two separate cases the screens actually show.

01M. AlvarezReview operationsSees both kinds of hold, whole‑day. Cannot open a single case.4 phases

02R. Okonkwo, RNClinical review32 denials, one clock each. Reveal‑then‑decide, every time.5 phases

03T. ReyesSpecial investigationsThe bill‑side mirror of Okonkwo. Her own queue was never built.5 phases

04M. OkaforCompliance, independentWatches the rate, not the case, on both sides. Paid on neither.2 x 4 phases

05The auditorCompliance, six months laterReads the locked record. No screen was ever built for her.3 phases

06The memberMarisol, and one otherEverything the desk sees, she never does — on one phone.5 phases

Role 01M. AlvarezReview operations, Florida Sees both kinds of hold in one place, whole‑day. Cannot open a single case. 4 phases · 1 screen

ScenarioStart of shift, Florida pilot, overnight decisions already run

GoalConfirm the floor is keeping pace, without opening a single chart or bill

TouchpointThe console (Screen A) — her only screen

	01Opens the console	02Scans the floor	03Checks the safety margin	04Confirms the guardrails hold
Screen	Screen A	Screen A	Screen A	Screen A
Doing	Checks overnight totals for the whole floor: 66,322 decisions, 1,412 held.	Reviews 8 reviewers, two teams, ranked by pace against deadline.	Reads the 13.3% blinded‑control share against a 10% floor.	Reviews the reference signals, shown to her, never scored.
Thinking	“How many held, and is anyone behind.”	“Never by anything the model produced.”	“Below this, the queue stops taking new cases.”	“The system explains itself, even to me.”
Experience

Opportunity

No case-level lever. Her only real action is staffing and capacity — she cannot open a chart, a bill, or anyone's finding from this screen.

Role 02R. Okonkwo, RNClinical review 32 denials, one clock each. Reveal‑then‑decide, every time. 5 phases · 3 screens

ScenarioClaim 5127, Wilma Traoré 71, Bayshore SNF, due 14:10 today

GoalDecide whether the model's denial holds, on the record, before the clock runs out

TouchpointsHer queue (Q) → the review (B1) → the record (B2)

	01Opens her queue	02Sees the flag first	03Reads the chart	04Writes her finding	05Commits
Screen	Screen Q	Screen B1	Screen B1	Screen B1	Screen B2
Doing	32 cases, ranked by deadline. Payment holds aren't hers to open.	Two named signals shown before the chart; the score stays hidden.	Open wound, IV antibiotic day 4 of 7, therapy minutes, the home she returns to.	Overturns, cites two documents. Won't record without a citation.	Her words lock in first and largest; the flag is demoted to a footnote.
Thinking	“Which one is due first.”	“Why was this held at all.”	“This doesn't hold up against what I'm reading.”	“This has to stand on the chart, not the flag.”	“This record is mine, and it can't be erased.”
Experience

Opportunities & edge states inside this journey

Waiting — records requested twice, day 17 of 30

Empty — queue clear, 4 unassigned cases to pick up instead

Refused — finding under 120 characters, will not commit

Role 03T. ReyesSpecial investigations The bill‑side mirror of Okonkwo. Her own queue was never built. 5 phases · 2 screens, 1 gap

ScenarioClaim 8814, Coastal Spine & Pain Institute, $487.00 due today at 16:40

GoalDecide whether the bill is supported as coded, without accusing anyone

TouchpointsNo queue (gap) → the review (D1) → the record (D2)

	01No queue to open	02Sees two checks first	03Reads the record	04Writes her finding	05Commits
Screen	Gap, not a screen	Screen D1	Screen D1	Screen D1	Screen D2
Doing	Opens claim 8814 directly — the screen that would list her cases doesn't exist.	Code‑versus‑documentation mismatch, plus a peer‑outlier flag that holds nothing alone.	41‑word note, 15‑minute slot, next patient booked at 09:30.	Not supported as coded. Re‑prices one line, cites the note and the schedule.	$331 of $487 pays today; a plain‑language remittance goes out.
Thinking	“Where do my cases even come from.”	“One of these is real. One is just a pattern.”	“This could look like fraud. It isn't, yet.”	“A billing correction. Not an accusation.”	“Paid, corrected, and nobody was accused of anything.”
Experience

Opportunities & edge states inside this journey

Clear and pay — Failure 01, a real pattern misread as a conclusion; only one of four reasons counts against model precision

Found: the console (Role 01's screen) lists T. Reyes on the RN / Clinical team. Both screens she actually opens name her special investigations, bill‑side. This journey follows the screens she opens, not the roster row.

Role 04M. OkaforCompliance, independent Watches the rate, not the case, on both sides. Paid on neither. 2 journeys · 2 screens

4a · Trip 04‑117 · home health denials, 7 days

ScenarioHome‑health denials break their band; zero tickets explain it

GoalExplain or release, inside 24 hours, without holding a single member's claim

TouchpointClass oversight (Screen C)

	01A signal trips, not a person	02Reviews why it tripped	03Watches the blind sample	04Records before the clock hits zero
Screen	Screen C	Screen C	Screen C	Screen C
Doing	Home‑health denials break their 9.1% ceiling at 13.4%.	Identical basis text on 1,943 denials since a calibration update.	60 cases, already paid, reviewed by people who don't know they're sampled.	Vacates 1,102 unsent denials; corrected notices for the rest.
Thinking	“Is this a policy change nobody registered.”	“This started with the model, not a person.”	“22% overturn against a 15% threshold — real, or noise.”	“The interval floor cleared. This is real.”
Experience

Cannot: hold a member's claim · recall notices already sent · see who reviewed what · extend the clock · release without a citation

4b · Trip 07‑042 · Coastal Spine & Pain Institute, 90 days

ScenarioOne provider bills level 5 at 61% against a 9% peer median

GoalExplain or close, inside 30 days, without stopping a single payment

TouchpointProvider oversight (Screen F)

	01A signal trips, not a person	02Names three explanations first	03Confronts the uncomfortable part	04Records before the clock hits zero
Screen	Screen F	Screen F	Screen F	Screen F
Doing	Coastal Spine bills level 5 at 61% across 33 matched practices.	Vendor template, case‑mix change, or upcoding — written before the sample.	Opening the trip was never disclosed to the provider.	Confirms prepayment review, sized to what this practice can survive.
Thinking	“An outlier is a question, not a finding.”	“So the answer can't be reverse‑engineered.”	“A harm I'm willing to cause has to be one I publish.”	“Costs them four days, not their contract.”
Experience

Cannot: stop or suspend payment · refer to law enforcement · terminate a contract · see which analyst reviewed what · close without a citation

Role 05The compliance auditorReads the record, six months later No screen was built for her. The record was. 3 phases · 0 screens

ScenarioA sample of forty records, pulled six months after the fact

GoalConfirm the original reasoning held, using only what was knowable then

TouchpointNone built — a deliberate gap

	01Pulls one of forty	02Opens the locked record	03Checks the reasoning
Screen	Gap, not a screen	Same append‑only card	—
Doing	At random, six months after a determination was recorded.	Finding first, citation attached, the signals visible at the time.	Against only what was knowable then.
Thinking	“No screen was built for me. The record was.”	“What did she actually know, when she decided.”	“Nothing here was left out to make the case look better.”
Experience

The design's honesty is legible without a bespoke interface built for her — that is Rule 04, stated as a role instead of a sentence.

Role 06The memberMarisol, on her phone Everything the desk sees, she never does. 5 phases · 4 screens

ScenarioBayshore Medical Group billed $18,240 for 14 office visits

GoalFind out whether she owes it, without having to fight for the answer

TouchpointsM1 → M2 → M3, one phone

	01A letter arrives	02Gets a plain answer	03Bayshore bills her anyway	04Given one small task	05Checks in later
Screen	Screen M1	Screen M1	Screen M2	Screen M2	Screen M3
Doing	Photographs it, asks the assistant what it means.	Plan didn't pay. She owes $0. Told not to pay if Bayshore bills her.	Taps through to report it.	Photograph the bill, wait for a call within 2 working days.	Sees the plan flag its own lateness on a second letter, unprompted.
Thinking	“Do I owe eighteen thousand dollars.”	“Finally, a straight answer.”	“They told me this could happen. It did.”	“At least it's something I can actually do.”	“They told on themselves before I had to ask.”
Experience

A second member, a different claim: when the plan is wrong first

Screen M4 — Gulf Coast Imaging, two knee scans held 18 days as a false duplicate. The plan opens with the admission, states it already paid in full, and only then asks whether a bill arrived during the hold — answering is optional.

Not journeyed here on purpose: the provider (Coastal Spine, Bayshore) receives the plain-language remittance and a 90-day appeal window, same as any billing correction. That rides the existing remittance and EDI pipeline — a CTO would route it there, not commission a fourth interface. Prototyped, not designed as part of this project.