Healthcare payers are under constant pressure to manage their appeals and grievances processing amid unpredictable workloads and disintegrated data flows across the enterprise.
Virtusa’s A&G solution offers simplified case management, and automated task handling, coupled with industry standard classifications, that ensure accelerated case resolution. The solution provides intuitive and guided workflows to help users navigate through the complex case life cycle. With Machine Learning at its core for decision making, the solution will enable medical directors to make smarter decisions.
Multilevel appeal escalation (to IRE, ALJ, MAC, and Judicial Review) is supported for adherence to Medicare Part C statutory requirements. Overall, Virtusa’s A&G solution helps payer organizations to effectively manage their Appeals and Grievances business and thereby achieve high customer satisfaction and better adherence to regulatory guidelines.
The solution segments the complex Appeals and Grievances process into concise, contained, and clearly defined activities routed selectively to the appropriate teams – Triager, Case Owner, Registered Nurse and Medical Director.
Targeted critical data
Display of relevant data up-front to support user decisions – enrich complaint case with authorization or claims data based on pre-service or post-service appeals.
Dynamic SLA Management
Ease of managing State specific and Line of business specific Service Levels mandated by regulatory guidelines.