Healthcare
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Revolutionizing Healthcare with Pega
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Healthcare organizations face revolutionary change that is disrupting the industry. This disruption requires revolutionary solutions that deliver the agility needed to promote growth, successfully manage constant change and deliver high-touch service in a world of retail healthcare, soaring costs and government regulations that squeeze profit margins.
Pega offers a transformational solution for “owning the change,” enabling healthcare organizations to rapidly re-architect their way of doing business. Pega advances operational excellence with dynamic processes that instantly adjust to each situation and individual, seamless interactions across all channels and end-to-end work automation that provides a controlled solution for leveraging, extending and replacing legacy systems.
These unique capabilities are complemented by Pega’s patented Build for Change® technology that delivers the power of innovation into the hands of business people. From sales, service, enrollment, and retention to care management, revenue cycle management, claims processing and more, Pega delivers the technology that drives innovation, better health outcomes, and outstanding customer experiences at lower cost.
Tab 1
Learn more about Pega solutions for Health Plans
| Claims | Pega optimizes high-volume, high-cost claims processes from streamlining product configuration and benefits management to increasing first-pass rates by automatically repairing problematic claims. Pega also increases claims operator productivity for finalizing pended claims, bringing end-to-end visibility and intelligent control to claims management organizations. View: Claims Workstation+ Solution Claims Repair Solution |
| Customer Relationship Management (CRM) | Pega CRM makes it easy to provide consistent, personalized service by turning best practices into intent-led processes that tailor each interaction to the member or provider, situation, channel and care setting. |
| Care Management | Pega’s care management capabilities enable healthcare payers to efficiently develop and manage high-touch programs for diverse populations, customizing and delivering individualized plans through a unified portal for utilization, disease and case management as well as health and wellness programs. |
| Sales Process Management | With Pega, payers can rapidly design and implement compelling acquisition strategies for groups and individuals, facilitating best-practice sales, rating and underwriting processes while streamlining product selection and enrollment processing. |
| Medicare/Medicaid | Pega’s intelligent automation drives efficiency, consistency and agility into the complex processes required to execute and manage Medicare and Medicaid programs, enabling error-free processing and immediate adjustment to changing regulations. |
| ICD-10 | Pega facilitates accurate ICD-10 coding with intent-led processes that guide users through the steps for determining the right code. Combined with conversion tables, reverse mapping, translation rule creation and ICD reporting and modeling, Pega helps healthcare organizations rapidly complete successful conversions from ICD-9. |
| Healthcare Industry Foundation | A foundation including healthcare data model, templates, data structures, solution design models, and HIPAA components to accelerate the development of Pega solutions for healthcare organizations. |
Tab 2
Learn more about Pega solutions for Providers
| Care Management | This transformational solution for complex care management offers adaptable ways to define and deliver customized care plans through a unified portal for such functions as utilization, disease and case management as well as health and wellness programs. |
| Revenue Cycle Management | This revenue cycle management solution uses intelligent automation to bridge organizational silos, automate manual processes and increase billing accuracy by improving the ‘First Pass’ clean bill rate. |
| Patient Call Management | Pega makes it easy to provide consistent, accurate answers and personalized service by turning best practices into intelligent, efficient processes that tailor each interaction to the patient, situation, channel and care setting. |
| ICD-10 | In order to leverage the true potential of ICD-10, your core business processes must be optimized so that you move beyond revenue neutrality to higher levels of quality, efficiency and healthcare coordination. |
| Medicare/Medicaid | Pega’s intelligent automation drives efficiency, consistency and agility into the complex processes required to execute and manage Medicare and Medicaid programs, enabling error-free processing and immediate adjustment to changing regulations. |
| Healthcare Industry Foundation | Pega facilitates accurate ICD-10 coding with intent-led processes that guide users through the steps for determining the right code. Combined with conversion tables, reverse mapping, translation rule creation and ICD reporting and modeling, Pega helps healthcare organizations rapidly complete successful conversions from ICD-9. |
Tab 3
Learn more about Pega solutions for PBMs
| Care Management | This transformational solution enables PBMs to efficiently develop and manage high-touch programs for diverse populations, customizing and delivering individualized care plans such as Drug Utilization Review through a unified portal. |
| Customer Relationship Management (CRM) | Pega CRM makes it easy to provide consistent, personalized service over any channel with intelligent processes that tailor the interaction to the member or provider, situation and channel. |
| ICD-10 | Pega facilitates accurate ICD-10 coding with intent-led processes that guide users through the steps for determining the right code. Combined with conversion tables, reverse mapping, translation rule creation and ICD reporting and modeling, Pega helps healthcare organizations rapidly complete successful conversions from ICD-9. |
| Medicare/Medicaid | Pega’s intelligent automation drives efficiency, consistency and agility into the complex processes required to execute and manage Medicare and Medicaid programs, enabling error-free processing and immediate adjustment to changing regulations. |
| Healthcare Industry Foundation | A foundation including healthcare data model, templates, data structures, solution design models, and HIPAA components to accelerate the development of Pega solutions for healthcare organizations. |
Tab 4
Learn more about Pega solutions for Health/Wellness
| Care Management | A robust, integrated medical management platform that spans and optimizes the entire care management continuum. |
| Customer Relationship Management (CRM) | Automate common member and provider service inquiries and delivers personalized responsive service through intent driven processes. |
Customer Success
Using Pega solutions, healthcare organizations have achieved rapid and measurable value.
