A Day In The Life Of VP Claims Operations - An Availity eGuide

A DAY IN THE LIFE OF

VP CLAIMS OPERATIONS

An Availity eGuide

©2016 Availity, LLC | AV2030-0516

http://www.availity.com

7:00 AM

Suzy is the Vice President of Claims Operations for a large health plan. She likes her job, but it’s challenging. She’s responsible for ensuring that her plan’s claims are processed accurately, efficiently, and in a timely manner.

SUZY SETTLES IN FOR A HARD

DAY’S WORK

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A DAY IN THE LIFE OF VP CLAIMS OPERATIONS | An Availity eGuide


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7:30 AM

SUZY SETS THE GAME PLAN

FOR THE DAY

Suzy just spent the past few minutes reviewing inventory reports and is now working with her management team to address any production issues, set the priorities for each sub-team, and facilitate the allocation of staff.

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9:00 AM

Suzy and her staff face a lot of challenges: complexity, changes, compliance. Even with electronic claim submissions at an all-time high, Suzy’s plan still receives a ton of claims that are incomplete, incorrect, or missing information.

CHANGES AND TRENDS

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10:00 AM

PANEL REVIEW WITH

PROVIDERS

Providers are giving Suzy an earful about denials, duplicates, changing codes and so on. She hears they’re willing to improve their claim submissions process, but they need the plan to provide clear instructions on what to fix.

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11:00 AM

CHAT WITH CUSTOMER

SERVICE COUNTERPART

Suzy’s staff isn’t the only one affected by bad claims. The customer service team spends a lot of time on queries, appeals, and requests for documentation from providers.

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1:00 PM

STARTS WORKING ON HER BUDGET

AND STAFFING PLAN

As Suzy works through her budget and staffing plan, she groans to herself about all the manual work and the high volume of claims inventory. She wonders how to reduce her labor costs, back-end recovery, and claim adjustments.

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3:00 PM

LOOKING FOR PROACTIVE SOLUTION

Suzy wonders if there is a way to correct claims before her plan receives them. This would save her team from manual re-work and from having to recover money on the back-end. Cleaner claims would allow Suzy to process more claims in a day, deny and pend fewer of them, and ensure prompt payment to providers.

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5:00 PM

GET IN LINE FOR IT

ENHANCEMENTS

Suzy knows whatever the silver bullet is, it has to stay within her budget, which currently doesn’t allow for new IT equipment or staff. She’s aware of claims editing systems on the market, but heard they require complex system integrations, expert users, and provider education.

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5:30 PM

GET IN LINE FOR IT

ENHANCEMENTS

The solution needs to be as close to “plug and play” as possible and require virtually no changes to her plan’s or providers’ existing claim processes. She’s confident her providers would adopt a solution for cleaner claims, but knows they don’t have the money or time to handle big changes and to retrain staff.

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Availity’s Advanced Claims Editor does exactly what Suzy wanted:

• Cleaner Claims

• Fewer Denials

• Less Manual Rework

• Happier Providers

To learn more, visit Availity.com/ACE

IT LOOKS LIKE SUZY FOUND A SOLUTION

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http://www.availity.com/ace





Healthcare

A Day In The Life Of VP Claims Operations - An Availity eGuide