Claims Processing

Project Background Major health care provider known for providing outstanding customer service and operational excellence
Business Challenge • Growth in volume led to performance of the claim process becoming unstable and unpredictable as real-time workflow reporting and process information were not available to process owners or participants
• Growth and acquisitions were pushing current process beyond its capability to meet member and provider SLA’s
• Claim Processor Supervisors and Sr. Claim Processors were spending too much time collecting, integrating and defining workflow data and as a result they were not spending time coaching and developing employees
Project Approach • Two person project team worked with cross-functional team of client staff, departmental management, IT, supervisors, process subject matter experts and executive management over 5 weeks to:
• Benchmark “As Is” claim process metric/report capability (inventory current metrics and criteria for claim process)
• Design “To Be” claim process metric/report (Dashboard and Scorecard) requirements
• Identify gaps between “As Is” and “To Be” metric report states
• Provide Level-1 “As Is” process map to identify process Key Performance Indicators (KPI’s) and Performance Indicators (PI’s)
• Establish metric/report standards for claim process that align with corporate values and strategies (Operational Excellence & Growth)
• Develop Level-1 “To Be” process map utilizing BPM best practices
• Provide Findings/Recommendations/Industry Best Practices
Business Benefits • Identified metrics that provide real-time visibility and process control
• Recommended Implementation of BPM solution that automatically prioritizes and routes work
• Brief review identified over $1,000,000 in cost savings, risk reductions, and process improvements
• Projected return on investment based on action plans of 500%, payback in less than six months

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