QNXT™ Claims Workflow helps healthcare organizations manage claim inventory more efficiently by automating the process of prioritizing, triaging and reducing pended and exception claims. The result is streamlined claims adjudication management, reduced costs and improved speed, accuracy, efficiency and compliance. Features include:

• Automatically manages and routes claims in real time to user work queues based on configured routing rules
• Automatic identification, prioritization and routing of work items based on specific data elements, user skills, lines of business and other variables
• Real-time delivery of work items
• Real-time views of employee work queues
• Natural language configuration of end-user desk-level procedures
• A real-time online dashboard provides snapshots of workflow status that show projected workloads by user or role

Designed to help plans manage the inventory of Utilization Management (UM) documents, QNXT™ Utilization Management Workflow helps healthcare organizations prioritize, triage and reduce lagging pended UM or referral requests. The result is improved efficiency, reduced costs, and enhanced supervisor and staff productivity. Features include:

• Automatic identification, prioritization and routing of UM documents to end users
• Real-time delivery of work items via seamless integration with QNXT™
• User-configurable UM queues
• Real-time views of employee utilization and work queues
• Natural language configuration of end-user desk-level requirements
• Prioritization of UM items to meet timely resolution and compliance requirements

QNXT™ Appeals and Grievance automates and manages the appeals, grievance and complaint process, electronically routing incidents to the right people using business rules you create. The result is lower cost and risk, greater efficiency and productivity, and improved member satisfaction. Appeals and Grievance helps healthcare organizations to:

• Reduce costs
• Track communications, documents and resolution timeframes in real time
• Prioritize work items and submit via streamlined, rules-driven routing
• Align tasks with appropriate personnel
• Adhere to applicable CMS and ACA timelines with client configuration
• Create comprehensive audit trails
• Alert users to at-risk, time-sensitive items
• Provide easy access to case files for CMS audits