Multi-Channel Intake Member & Provider Info Edits Member Eligibility Validations Medical Necessity Validations Review Case Determination Claim Processing Audit Claims Adjudication Claim Payment Adjustments High Dollar Claims Audits Post-Authorization Case Review
Member & Provider Info Edits
Member Eligibility Validations
Claims management.
Claims strategy and planning.
Claims Strategy development, Catastrophe planning, Plan Catastrope resources, Simulate loss projections, Provider planning
Climas review and audit
Determine claims reviews, Conduct claims leakage reviews.
Claims analytics and reporting
Claims leakage analysis and reports. Cost of claims analysis and reports, Claims lifecycle analysis, Catastrophe claims Analysis, Litigation outcome analysis
Claims reserve management
Administer anticipated claims, Evaluate claims reserve
Claims notification
Capture claim and claimant information, Validate claims data submission, Notify interested third parties
Fraud management
Detect potential fraud, Investigate potential fraud, Prosecute Claims Fraud
Claims handling and adjustement
Investigate claim, Determine claim settlement, Setle claim
Claims recovery
identify subrogation, re cover subrogation, identify salvage, Sell Salvage, Manage claims contributions, Manage collectivle deductibles
Dispute resolution
Manage arbitration, Manage litigation
Claims inquery
Provide claims status, provide claims service status
CheckHigh Risk Member Identification
Member Outreach Scheduling
Risk Assessment
Personalized Care Plan
Duplicate Case Identification & Merge
Eligibility Management
Questionnaire Management
Member Clinical History Data Gathering
Member Correspondence Letter Generation
Scheduling Appointments
Monitoring Progress
Care Management
As a key healthcare partner, you want to deliver innovative programs that help improve clinical outcomes and ensure at-risk members get treatment on time. With a full view of patient health information, as well as individualized member insights, you can collaborate with providers and engage with members effectively.
Task
Automate Care Manual data entry and processing.
CheckHigh Risk Member Identification
Member Outreach Scheduling
Underwriting
Underwriting analytics
Underwriting profit / loss ratio, Re-insurance ceding limits, Risk pool analysis, Risk acceptance limit adjustement, Premium adjustement viability analysis, Third-party data aggregation, Third-party data impact analysis
Renewal inderwriting
Premium re-calculation, Rsik assesment, Underwriting approval, Approval of premium adjustements Policy cancellation - unacceptable risk.
New business underwritingFinal or rated premium calculation, Risk assesment, underwriting approval, Premium adjustements, Policy decline, Requirement management, Suitability analysis (annuity), know your customer validation, Anti-money laundering validation, Reinsurance analysis
CheckHigh Risk Member Identification
Member Outreach Scheduling
Billing and Payments
Invoicing and collection
Administer invoicing, Maintain billing history, Resolve billing disputes, Produce billing Statements, Manage Collections.
Payment management
Manage unsolicited incoming payents, Apply premium remittance /deposits, Issue payment.
CheckHigh Risk Member Identification
Member Outreach Scheduling
Customer service and operations
Customer relationship
Customer retention strategy, Customer interation management, Service bundling / customization, anage customer requests, Manage cutomer satisfaction, Manage Customer retention, Administer customer information, Initiate contat with customer.
Customer analytics
Analyze customer profitability, Analyze customer buying, Analyze customer interactions, Analyze customer satisfaction.
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