The many faces and places of case management
What do an attorney, a fraud investigator, a claims analyst and a medical credentialing specialist have in common?
Answer: Nothing. And everything! While these professionals are wildly different on the surface, they all share core underlying requirements in how they have to handle their work.
Contract management, fraud investigation management, claims processing and medical credentialing all involve:
- A need to gather, organize and coordinate information, data and documents
- A need for ongoing evaluation, assessment and review
- The requirement of a knowledge worker (often several knowledge workers) to make decisions
- A need to be prepared for internal/external audits
- The need to manage compliance
And these requirements make all of these areas well-suited to a case management solution approach.
“Case management?” you may ask. “Isn’t that a niche term for specific industries?”
A common misconception exists that case management only has a play in certain industries like social services, where it undeniably has long-time roots. However, over the past few years, case management software capabilities have provided value for a range of solutions across every industry and many types of work.
Let’s take a look at how the principles above connect seemingly unrelated processes, making them excellent candidates for a case management solution.
All organizations have a need to store and manage contracts, amendments, key third-party information and other supporting content that defines relationships and obligations. Once approved and executed, contracts come up for review and renewal at specific time periods, requiring attorneys or contract administrators to update information and decide whether to renew, renegotiate or terminate agreements.
Audits can happen at any time, so organizations must always be prepared to provide timely access to contract information, documentation and a history of interactions.
When a suspicious transaction or some other event triggers the start of an investigation, investigators need to gather and organize all information and supporting content related to that target (client, organization, etc.). Next, they analyze and evaluate the evidence to make an effective decision: whether this is indeed a fraudulent transaction or just a false alarm.
Audits can happen at any time, so organizations must always be prepared to quickly show documented proof of all steps taken during an investigation to avoid fines and penalties.
When a customer makes a claim on a policy, the claims adjuster must review and assess the claim, gathering all related information – from underwriting decisions to claim history. The adjuster assesses all information – including first notice of loss documents, medical bills and correspondence – in order to make a decision on approving the claim.
Once again, audits can happen at any time, so insurance organizations must be prepared to show an audit trail and evidence that supports the adjusters’ decision process.
For each clinician a hospital or healthcare organization employs, it needs to collect, organize and store background information and all appropriate accreditations, certifications and licenses, as well as other details such as degree and continuing education information. That’s a lot of information. And these credentials must be assessed, updated and evaluated on a regular basis by credentialing specialists to identify any deficiencies.
As you guessed, audits can happen at any time, so all credentialing information and supporting documentation must be current and immediately accessible to avoid penalties.
In addition to sharing common requirements, these processes also share a legacy of ineffective handling via tools like Excel spreadsheets, email inboxes, disorganized network shares, paper files and antiquated Access and Lotus Notes databases.
4 + 4 =1
Four different areas, four types of knowledge workers, four unique problems, four opportunities for one effective case management approach.
The right case management platform has the configurability and flexibility to solve all these issues and more – with unlimited potential for applications that empower knowledge workers with 360-degree views of information and the ability to improve collaboration, task management and customer service.
So, do you have work that can benefit from case management capabilities?