Streamline Grievances and Complaints and Deliver Patient-centered Outcomes

Centralized Case Management

Capture and create cases from diverse channels, including web portals, mailrooms, and faxes. Ingest data from CRMs and external systems in a hassle-free manner. Manage all types of complaint, including quality of care, quality of service, enrollment, and customer service, ensuring structured resolutions. Use AI to summarize complaints and analyze sentiment, ensuring no complaints go unnoticed.

Intelligent Mailroom, Data Enrichment, and Case Assignment

Ensure robust integration with advanced document processing capabilities to manage incoming documents effectively. Fetch eligibility, claims, and authorization details from core systems. Delegate cases based on the skills and expertise of coordinators. Prevent fraudulent activities with duplicate detection, and easily identify closed or similar cases to add additional information for quicker resolution.

Collaboration, Communication, and Audit readiness

Foster cross-team collaboration, enabling nurses, doctors, and operational admins to review and redirect cases on a unified platform. Capture case research automatically for audits. Create detailed case packets for audits and external reviews, ensuring accountability and compliance. Generate compliant letters without any manual intervention.

Advanced Search, Reporting, and Oversight

Employ quick and advanced search capabilities to retrieve cases based on the type and specific criteria throughout the lifecycle. Access detailed dashboards for 360-degree visibility into member or provider cases. Generate operational, compliance, and business intelligence reports. Tailor business reports to meet specific requirements or integrate custom modules.

Integrated Quality Assurance and Performance Evaluation

Implement sampling algorithms to evaluate coordinator efficiency and work accuracy. Ensure thorough case reviews with detailed checklists. Assign performance scores for coordinators and enable bi-directional communication between auditors and researchers for addressing changes. Provide custom and distinct views for intake workers, research coordinators, QA auditors, supervisors, and managers.

Comprehensive Case History and Issue Management

Capture complete case histories, including decisions, notes, and exceptions, for future reference. Manage multiple issues within a case grid, categorized by the National Committee of Quality Assurance (NCQA) and Health Plan Management System (HPMS), for efficient segregation and resolutions.