US HealthPlan Business Operations Management Product

Workflow Plus™ is a US HealthPlan Business Operations Management Product used to optimize operational processes by automating work assignments, auditing, SLA compliance monitoring, and implementing operational efficiencies. It can be used by any business operations team in any health plan ecosystem in the US that needs to efficiently manage the work, workforce, operations service levels, and meet compliance needs. Our core team, consisting of experts/leaders who have worked in Health Plans, assists health plans in business management consultancy and advisory capacity.

The core functions of Workflow Plus™ include Claims Operations, Enrollment Operations and Audit Function. Workflow Plus™ offers the capabilities of automatic work/task allocation, task management, task process optimization, allocation, prioritization, tracking, and reporting that includes workforce productivity management, performance management, operations & compliance service levels management, audit functions, and business operations governance in any health plan business operations. Workflow Plus™ product can be easily deployed in any US health plan ecosystem.

Integrated with CAPS solution
Workflow Plus™ product can be integrated with any Core Administrative Processing System (currently pre-integrated with HealthEdge’s HealthRules Payer), which helps the Examiner or Auditor to directly access CAPS to perform their responsibilities in Health Plan business operations.

Queuing and Routing
Workflow Plus™ has an automated queuing and routing mechanism to assign tasks and auto-prioritize the tasks based on configured business rules.

Workflow Management
The Workflow Plus™ product helps to manage the lifecycle of the Claim and enrolment processing from Complete, Pend, and Route the Claim to Audit, Correction, and Review.

User Management
Workflow Plus™ product can also Add, Modify, Remove, and Manage users and user groups.

SLA and Productivity Management
The tasks assigned and performed using the Workflow Plus™ product are time-tracked and used for SLA/KPI and productivity management.

Real-Time Dashboards
Workflow Plus™ provides real-time dashboards on business operations tasks. Dashboards are available for all types of users on tracking operations, performance, quality & SLAs.

Automated Audit Sampling
The transactions to be audited can be pulled using automatic sampling rules.

Audit Process Flow Management
The end-to-end Audit flow cycle includes Audit, Rebuttal, Correction, and Review as part of the Workflow Plus™ improving communication and collaboration between business users. . Managers and Leads can analyze the audit data through reports and dashboards to drive quality improvement plans.

Configuration Feasibility
Workflow Plus™ product features are configurable based on the needs of the operations management team.

Upcoming Key Features for 2024

  • Scheduling of audit task assignments using audit grids. Create and save audit sampling criteria(s).
  • Configuration of Workflow Plus™ to support operational and compliance needs of a HealthPlan that operates in Multimarket or Multistate.
  • Enablement of Workflow Plus™ for running Provider Data Management Operations, Claims Authorization
  • Enablement of Workflow Plus™ to manage inter-department workflows/tasks to HealthPlan Business Operations from various departments and ticketing systems of Health Plans.
  • Auto-create fallout resolution tasks in the UST HealthProof ecosystem integrated using the product Integration PlusTM.
  • AI-driven Audit function.