client: A LEADING HEALTHCARE COMPANY
VERTICAL: HEALTHCARE
PRACTICE: BPM - PEGA
Project
Encounter Work Flow Management (EWFM)

This leading healthcare company focuses on providing government-sponsored managed care services through Medicaid and Medicare Plans to families, children, seniors and individuals with complex medical needs. This project objective was to build a case management tool that allows their users to analyze and update/correct the fallout cases that are being created out of withheld and state reject encounters coming from the client’s Encounters Processing System (EPS). The EWFM will batch these fallout cases based on user defined grouping logic into individual batch cases based on user batching criteria. Once the batches are created, the system will assign batches to the user based on the priority score. User can analyze the batches and make necessary updates to correct these encounters.

Maantic was involved in the following:

  • Business Process Analysis, Requirement gathering, Design and Development
  • Solution Architecture for enhancing the EWFM application into a Claims Processing platform bringing other similar applications like Claimspath into the fold
  • First time successful DCO Adoption and setting a precedence to follow in the company
  • Quick delivery to market (First Phase of product delivered in 70 Business days)
  • High reuse of Pega HCIF & CWS’s data model, features and functionalities
  • Customized Pega v7.2.2 to build Batch case processing
  • Integration with multiple in-house systems
  • High number of Business delegated functions limiting IT involvement
  • Pega enablement and mentoring program for FTEs
  • Design documents, production roll out model, transition documents and training plans
  • Application maintenance and enhancements
  • Tuned system architecture and optimized code for performance improvement
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