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Presentation Title Presentation Title Second Line
AuthorTitle
Cognizant & BCBSNC: Leveraging Pega Platform to Deliver Innovative Quote to Card Solution Using Six Sigma Techniques
©2016 Pegasystems Inc.
Jim FultonDirector, IT Delivery, BCBSNC Harish DwarkanhalliVice President, CognizantDev VictorienEngagement Leader, Cognizant
Pega & Cognizant HealthCare Journey:
2
Yesterday
Tomorrow
Today
Business Process Management (BPM)Business Rules Management (BRM)Case Management (CM)
Customer Relationship Management (CRM)Customer Experience Management
DigitizationAutomation
New Horizons
PRPC & Frameworks
Decision Hub
CHANGED How Process & Rules
are Managed
CHANGING How Relationship & Experience
are Managed
WILL CHANGEHow Business is
Automated & DigitizedYesterday-Today-Tomorrow
Clai
ms
Claims Intake
Pre-Processing
Benefit Adjudication
Post-Processing
Pega & Cognizant HealthCare Journey
3
Member Data Input
Group Setup
Member Setup
Member OnboardingEn
rollm
ent
Prospecting
Provider Data Maint
Credentialing
Contracting
Prov
ider
Net
wor
k M
anag
emen
t
Utilization Management
Disease Management
Case Management
WellnessCare
Man
agem
ent
Core PRPC FoundationHealthCare Industry Framework (HCIF)
Additional Frameworks – GSPM, ISPM, PCS, CW, CR, SCE, CMF
Yesterday (BPM, BRM, CM) – Heat Map
Core PRPC FoundationHealthCare Industry Framework (HCIF)
Decision Hub – DSM, PAD, ADM, VBD, ESM
Pega & Cognizant HealthCare Journey
4
Mar
ketin
g
Market Study
Plan Creation
Marketing Collateral Management
Campaign Management
Census Management
Lead Management
Quote Generation
Negotiation & Closure
Sale
s
Cus
tom
er S
ervi
ce
Contact Center
Appeals and Grievance
Member Portal
Member Communication
Today (CRM, CX) – Heat Map
Pega & Cognizant HealthCare Journey
5A
utom
atio
n
Dig
itiza
tion
New
Hor
izon
s
Cog
nitiv
e B
PM
Workforce Intelligence
Robotic Process Automation
Robotic DesktopAutomation
Mac
hine
Lea
rnin
g
Tomorrow
Pega & Cognizant HealthCare Journey
6
Clai
ms
Reduction in processing time80%
Reduction in claims
processing time75%
Reduction in IT cost for claims
processing10%
Reduction intime for duplicate
claims check98%
CMS Compliance100%
Reduction in time for
User Training71%
Reductionin TAT80%
CallAdherence 100%
Care
Man
agem
ent
Enro
llmen
t
Reduction in Onboarding Time50%
End to End Traceability100%
Prov
ider
Net
wor
k M
anag
emen
t
Reduction in Process Step
Count66%
Reduction in Turn Around Time90%
Reduction in Average Call
Handling Time35%
Increase in Number of
Requests Handled 24%
Cust
omer
Ser
vice
Delivered Benefits
+ North Carolina’s largest health insurer
+ Founded in 1933
+ Employ more then 4,700 North Carolinians
+ Serve more than 3.89 million members
Blue Cross Blue Shield of North Carolina
7
Business Process Improvement
9
Input Measures Output / Outcome MeasuresProcess Measures
“What gets measured gets managed.” – Peter Drucker
Account Implementation Fulfillment (ID) Fulfillment (Booklet)
Renewal Sales MembershipNew Sales
Sign Me Up Value Stream
11
Operations personnel update their status in multiple locations using various systems and spreadsheets so Sales Representatives and Operations Management can keep track of group and member enrollment activities.
Account Implementation Member Enrollment (AIME)
12
• Eliminate the need to perform manual work in multiple systems and various desktop tools used to track and report work progress
• Provide Executive Dashboards for Key Performance Indicator tracking and Operational Metrics
• Streamline the end to end process and use data captured during the process to dynamically change the step assignments in real time to maximize efficiency
• Integrate our SFDC and PEGA technologies to manage hundreds of steps performed by over 165 users across the Enterprise
AIME Project Objectives
Transition from Process / Measures to Pega / SLA
13
Planning Business Requirements
FunctionalRequirements
Tech Design &
DevelopmentTesting Go-
Live
Assignment
TopCase
Sub-Case
SystemSetup
Business Process Consultants and IT Systems Analyst Partnership
Assignmentq Individual SLA
(Cycle Time)q User Interface
AIME – Case Management
1515
Case / Sub Caseq Process SLA
(Lead Time)
AIME
Pre Sale Post Sale Enrollment Custom ID Custom Booklet
Pre SaleCGS
Submit GEO …
Discovery Call…
Complete Group Level
…
Submit ID Card Request
…
Build Custom Booklet Template
…
Top CaseSub CaseAssignment
Legend
AIME Screenshot – SLA Configured by Business
16
SLA Measures: Goal / Deadline, Unit & NotifySLA Dynamic RulesSLA DirectionSub-Case / Assignment
AIME Screenshot – Workbasket Assignments
1717
SLA Deadlines Set Assignment PriorityBusiness Can Also Set Priority
Case, Sub-Case and Assignment Deadlines Drive Priority
AIME Dashboard – Real Time Six Sigma
20
Real Time Tracking:• Lead Time• Cycle Time• Resource Utilization• SLA
AIME Outcome
21
• AIME was delivered in 6 months with BCBSNC resources and Cognizant onshore and offshore resources
• AIME consist of seven sub-cases with over 50 assignments and tracks activities of over 165 users across the Enterprise
• AIME delivered $1.1M cost savings by eliminating waste –Sales staff spent over $500K worth of their time checking
on status –Operations staff spent over $600K of their time manually
reporting status
IT and BPE Joint Assessment Methodology
22
Observation & Data Collection
As-Is Process Mapping
Data Analysis
Process & Technology Proposals
SolutionRecommendation
Business Benefits & Roadmap