Our client, a large regional health plan serving nearly 3.5 million members, realized that their clinical professionals weren’t operating at the top of their licenses due to the rules-based, rote tasks involved in managing the plan’s Utilization Management (UM) program. These tasks were negatively affecting job satisfaction in a highly competitive talent market.
Our client reviewed their process and determined that the manual generation of UM letters, which included more than 20 steps to send a letter, was inefficient. It turned to Cognizant to launch a pilot program to automate the process. The client implemented our TriZetto® Clinical CareAdvance® solution which enables the plan’s clinicians to activate predefined business rules to generate UM letters. This allows the clinicians to easily select and activate a rule, then move on to the next case.
The solution standardizes the UM process, minimizing the potential for errors and improving the quality of case completion. Clinicians can now complete more authorizations in a day and focus their attention on more complex clinical reviews. Automation enabled 600 authorizations to be completed in a single day. This resulted in better productivity, saving over 9 hours and increasing UM team capacity by one extra full-time employee. When applied across the client’s 100 clinicians, the client will be able to reallocate 33 hours of work a day. In addition, members and providers will receive coverage decisions sooner and the client expects to see a reduction in administrative spend which will positively impact member premiums.
authorizations daily
hours of productivity daily
potential hours saved daily
