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Claims operations and inventory management

Suggest edit Updated on August 31, 2021

This group of features provides the tools and infrastructure for a claims operations department to manage inventory and workload, as well as performing key tasks such as pend resolution, adjustments, auditing and claims inquiries.

Dashboards and reports are available to provide insight into the day to day operations and help identify trends.

CapabilityDescription
Inventory management

The SCE supports inventory management by ensuring the right work is retrieved by the correct operators and that work can be transferred appropriately when needed.

  • Mass transfer / claim transfer
  • Skills assignment / routing
Pend management

The SCE supports pend management via a variety of tools. These include the ability to search for members and associated claims, a guided pend resolution process and support for mass reprocess when a high-volume issue is resolved.

  • Guided pend resolution
  • Mass re-process
  • Approve/correct/deny
  • Member search
  • 360 claims search and view
Adjustments & voids

The SCE supports adjustments and voids utilizing the single and mass claims adjustment tools. Mass adjustments can also identify the impact and schedule the subsequent processing.

  • Claim adjustment & void
  • Mass adjustment management
  • Mass adjustment processing
Dashboards & reporting

The SCE provides dashboards for both claim and system operations. Reports showing productivity and errors are also available. Individual and mass communications can be provided by the notifications and Pulse capabilities.

  • Claim reports
  • Inventory reports
  • Dashboards & KPIs
  • Notifications & Pulse
Claim inquiry

The SCE manages claims inquiries from initiation through completion with a robust case management model.

  • Claim inquiry case management
Audits

The SCE provides configurations for random audits for claims and examiner work. This ensures that claims are adjudicated correctly.

  • Random audit
  • Examiner audit
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