Improved provider experience by Claims transformation program with a goal to develop a future state, modernized process. It also made the system more lucid, meticulous and efficient. Pega Smart Claim Engine platform is helping the organization realize its target of enhanced the provider outcome & experience and thus driving growth.

Created a Centralized desktop for a healthcare payer using Pega Customer Service that guides back-office associates through complex processes, making it easier for them to offer an improved, frictionless experience to consumers. The desktop service intelligently centralizes and organizes data so that each customer service engagement is personalized and exceptional. Customer service representatives are given the right content, instructions, and links at the right time, reducing dependency on training and experience.

Designed and Developed a Customer Service application to reduce member and provider call processing times and to improve user efficiency. This application serves as a one stop shop for members and providers with inquiries, ID cards, material requests, eligibility, updates, enrollment, claims, and billing.

Automated work assignment and processing using Pega Robotics by integrating with Queue Management System to rate the complexity to simple, medium & complex from the common queue and allocating it to agents according to their skills, experience, and expertise rating. Bot directly processes work without any human intervention for straightforward cases. This helped in reducing human dependency, repurpose existing human efforts for more critical tasks and turnaround time for work assignments and processing.

Enhanced the member experience with regard to the Appeals and Grievances process. Re-Architected and Upgraded to the latest Pega version to improve performance and usability as well as to address existing shortcomings in the application.

Implemented a comprehensive Knowledge Management system utilizing Pega PRPC platform and Pega Knowledge Management (PKM) framework to help customer service representatives in quickly accessing documents/content.

RPA solution was developed to automate the HealthCare Verification process, to extract the patient appointment lists from each healthcare provider’s practice portal across all provider locations. It then prioritizes the appointments for further processing, extract appointment details by accessing two different applications and 14 screens, consolidate the output reports and confirm whether patients are eligible for benefits, validates, and updates eligibility and benefits details in each practice’s portal. This eliminates the divide between the administrative system to automate a complex time-consuming verification process with hundreds of business rules without requiring any code changes to the legacy system. 

Developed an end to end Pharmacy Home System to support, map and monitor a beneficiary to a particular pharmacy.

Enabled Cloud and Real time data integration for improved HealthCare service offerings and data usage points.

Redesigned the Group Sales Management system by automating the new group enrollment, renewal, group contract changes, quote management and underwriting processes.

An established insurance group has a 100% manual policy reassurance process to capture 300+ data points, compare between 2 separate systems plus process differs by geo & producing office. Their volumes were also growing at 2x YoY.  This causes bandwidth constraints which result in backlog in policy creation. RPA solution helps the organization streamlines the process of handling increased volumes without adding new headcount hence increased efficiency of 50%. RPA improves process efficiency by reducing the baseline average handling time by 25%. RPA reporting provides 100% process visibility and data challenges which helps the operations team resolve the backlogs with a swift resolution.  RPA also drives accuracy, compliance, and reduces corporate risks.

Enhanced the Omni channel customer service experience for current users and added new users as part of M & A. Integrated with new enterprise systems and upgraded to the latest Pega Customer Service Framework from their legacy Customer Process Framework.

The process of Credentialing starts when the claimed source is from a non-service network. Before attending the claim, the company has to verify the validity of the practitioner license along with other criteria. RDA bots are triggers and it takes the physicians details from the claim documents & prescription.  It retrieves the physician details from Applied Medical Systems & matches the medical license with appropriate licensing agencies. This transforms the existing provider credentialing and claims processing environment to achieve higher quality, faster turnaround times, reduced TCO and reduces time spent on credentialing to allow more focus on claims processing.

Customer care center for a large publicly-traded company and a multi-line managed care enterprise spend more time in validating customers across multiple back end systems while the customer is on call. Multiple client system access by customer care agents while on call to answer customer queries. RDA solutions help reduce human dependency on performing basis day to day mundane tasks with standard processes/steps. RDA BOT retrieves relevant customer, policy & transaction information from back end systems and pushed to the Pega Customer Service framework to populate on the agent interface. If customer requests to update any of this information in the Pega Customer Service interface, RDA bot triggers the automation to update this information back in the relevant backend system.  Leveraging automation on top of the email, chat & voice solution ensures integrity between the client’s various processing systems and system of record. It helps in the reduction of handling time and the increased human capacity for complex issue resolution by up to 15%.

Designed and developed a Case Management Solution to handle unique Appeals and Complaints process flows of different Lines Of Businesses. This eliminated the manual effort required to comply with Federal SLAs and ultimately avoid fines and penalties.