Streamlined solutions for healthcare payers
Offer seamless member-centric care
Drive proactive, efficient experiences at every stage of the health journey using Pega’s unified platform. AI and automation streamline workflows so teams can offer more personalized, effective, holistic experiences that improve both health and business outcomes. Processes that are more member-centric let you stay on top of what employees and members need, in real time.
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Navigate healthcare complexity seamlessly
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Empower better health outcomes at every step
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Remove barriers to holistic care
Featured customers
Learn how this health benefit leader saw a 50% decrease in associate training time and an 11-point increase in NPS.
Learn how enGen, a Highmark subsidiary, brought down annual medical costs by $17 million while improving experiences.
See how this nonprofit health insurer seamlessly enrolled over 250,000 new members with efficient, digital service.
Personalized engagement
Treat each member with care
Every interaction is a chance to connect deeply and build trust. Assess member needs in real time to build greater understanding of their health, administrative, and financial needs. By personalizing experiences across channels, payers make wellness more engaging, while improving outcomes.
How we do it
- Continuously optimize systems, data, and analytics for a unified experience
- Personalize engagement with industry-leading real-time decisioning and AI
- Serve empathetic next best actions that align with what members need
Customer service
Simplify every experience
Make every interaction as effective as possible. Pega’s industry leading platform helps payers solve problems, recommend personalized actions, and offer proactive solutions, all while continuously learning and optimizing in real time, across channels.
How we do it
- Ensure team success with AI co-pilots that give every call an expert tone
- Proactively and seamlessly engage members in their channel of choice
- Get more from current systems by layering in agility and scalability
Streamline operations
Seamlessly connect systems
Bring together all your systems, processes, and data so you can approach change with an agile approach. Applying AI and automation reduces manual work, decreases errors, and improves efficiency and productivity to keep operations up to speed and compliant – no matter what.
How we do it
- Connect work across the organization without disruption with a unified platform
- Configure workflows, benefits, and plan features for optimized admin processes
- Simplify maintenance to quickly meet changing business needs and requirements
Orchestrated care management
Bridge gaps in care
Centralize medical services, approvals, and all relevant information with advanced consumer engagement and workflow automation. Deliver proactive, consistent member-centric care to ease the stress of navigating appointments and paperwork – when they need it most.
How we do it
- Use real-time data for to inform better care experiences
- Unify data to anticipate patient needs and proactively address gaps
- Maintain care continuity and improve outcomes with data-driven engagement
Onboarding & enrollment
Build loyalty from the start
Streamline enrollment for members, while making onboarding and credentialing for providers faster and more accurate. Accelerate processes, deepen relationships, and respond with due diligence from the get-go to reduce cost and manual effort.
How we do it
- Seamlessly manage workflows – from simple to complex – at scale
- Gain transparency to see what’s getting done and how, and what’s next
- Accommodate needs quickly with prebuilt accelerators
Robust claim management
Streamline operations for all
As claims volume grows, healthcare payers need a scalable approach to processing. Improve the efficiency of claims handling on high volumes of member, provider, and employee transactions to cut costs and ensure timely patient care.
How we do it
- Eliminate manual interventions with AI decisioning and automated workflows
- Adapt to regulatory and organizational changes with flexible workflows
- Enhance speed and accuracy with dynamic routing based on complexity
