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From Manual to Digital: The Future of Grievance & Appeals Process Efficiency

In the ever-evolving landscape of customer (member) management, organizations face the challenge of efficiently handling appeals and grievances while meeting governance, compliance, and customer satisfaction requirements. Manual processes and disjointed systems can hinder productivity, lead to inefficiencies, and compromise the overall customer experience.

Harness Technology for Better Customer Management and Transform your Grievance & Appeals Process

Discover 6 ways an automated solution can transform your G&A process to be more productive:

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With a robust appeals and grievances platform, organizations can unlock a range of capabilities that deliver tangible benefits.

01

Streamlined Case Management

Our comprehensive grievances and appeals platform offers both simple and complex case management capabilities, powered by the HL7 FHIR data framework. This empowers organizations to handle a diverse range of cases efficiently. Whether it’s a straightforward appeal or a complex situation, the platform provides a centralized, user-friendly interface to manage cases from start to finish, ensuring consistent and compliant processes.
02

Consistently Improved Case Outcomes through Playbooks

Step-by-step playbooks within the platform enable organizations to consistently manage every case, aligning with governance and compliance requirements. These playbooks serve as a guide, ensuring that every step is followed, essential documentation is collected, and appropriate actions are taken. With playbooks, organizations can uphold quality standards, reduce errors, and improve overall case outcomes.
03

Live Virtual Agent Support

The inclusion of a virtual agent in the appeals and grievances platform offers substantial benefits. By leveraging Natural Language Processing (NLP) and sentiment analysis, the virtual agent can capture data points and provider needs accurately. It acts as the first line of support, engaging with members or providers and gathering essential information. This AI-powered assistance reduces the effort required from members and enables a faster and more efficient case resolution process.
04

Fully Auditable Documentation

Compliance is a crucial aspect of appeals and grievances management. The platform ensures that all case-related interactions, from initial virtual chats to final case resolution, are thoroughly documented and auditable. This documentation meets compliance requirements, offers transparency, and helps organizations track the history and progression of each case. It also supports effective audits, investigations, and reporting.
05

SLAs for Enhanced Accountability

Service Level Agreements (SLAs) play a pivotal role in maintaining provider contracts and meeting product requirements. The appeals and grievances platform facilitates SLAs at both the case and task levels. This allows organizations to set performance benchmarks, measure adherence to timelines, and ensure accountability. Meeting SLAs enhances customer satisfaction, strengthens relationships with providers, and instills trust in the process.
06

AI & Automation in Action

The integration of AI and automation technologies provides an additional layer of efficiency and intelligence to the platform. The virtual agent leverages NLP and sentiment analysis to capture and
understand data points accurately, improving data quality and relevance. The platform's intelligent capabilities categorize and prioritize cases, routing them to the right resources with the required
skills. Furthermore, powered searches across multiple knowledge bases and repositories deliver contextual help, empowering agents with comprehensive information to resolve cases efficiently.

Ready to Revolutionize your Grievance & Appeals Workflow & Optimize Customer Satisfaction?

Try our exclusive, automated solution today. This first-of-its-kind innovation builds on ServiceNow’s new HCLS Service Management Core, expanding capabilities to Payers with a single source of action. Now, you can seamlessly connect Service Reps with middle office and the back office for a frictionless experience that fuels efficiency, elevates service and revolutionizes the member experience.

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