Portals
Pega Care Management includes these portals: Interaction portal, Care Management,
Utilization Management, Business Analyst, and Customer Interaction. The Interaction portal provides better customer experience by using Pega-provided
features for care management using customer service capabilities. A key flow such as
program referral is exposed in this portal so that a Pega Care Management representative
can easily complete the intake process for the member. The control is then passed to a
clinical person to manage the case further. There are different tasks available, based
on whether the calling person is a patient or provider. Also, there is an option of
making outbound call to the patients when needed. You can initiate inbound and outbound
calls, chat sessions, and co-browse sessions with patient and provider, and can access
the Knowledge Management portal if needed during any of the conversations with a patient
or provider. For more information about this portal, seeUnified Interaction portal. The Care Management portal allows for the management of patients who are either enrolled
in a program or being managed outside of a program, thereby providing a complete picture
of the patient’s current and past health status. The portal provides a full 360 view of
the patient and allows for the customization, tracking, and management of problems,
goals, interventions, barriers, and programs. It allows the aggregation of data to
present a full 360-degree view of the patient in a single system. The Utilization Management portals allow utilization management staff to enter and review
referrals, authorizations, admissions with a medical necessity review (including
initial and concurrent) with discharge and transition planning, while maintaining
visibility to urgency and next work. Integrated clinical vendor guidelines available for
seamless embedded medical necessity review. Attachments are easily managed and easy to
find. The Business Analyst portal allows a business analyst to configure care templates, define
goals, alerts, programs, and problems to build care plans and care programs. This
streamlines the ability to launch care for a subset of patients and creates a framework
from which a care plan and program personalization can begin. Pega Care Management supports key roles that are associated with your day-to-day use
of the application. The following table describes the key access roles that are provided
with Pega Care Management. Primary Portal: Pega KnowledgeRoles and portals in Pega Care Management
Role Description Portal Configurator A business user who configures business rules in the Business
Analyst portal. Primary Portal: Business Analyst Portal Fulfillment A user who is responsible for setting up materials that can be
generated for patients and caregivers based on information received such
as biometric devices and knowledge articles. Care Triage A clinical user who works directly with patients on managing care
plans and care protocols. Primary Portal: CMF Support Portal Care Manager A clinical user who works directly with patients on managing care
plans and care protocols. The care manager works with the patient to
complete assessments, engages in outbound calls to external care team
members, advocates for the patient, and reviews and manages programs and
the care plan with the patient. Primary Portal: CMF Manager Portal Medical Director A user who reviews, consults and engages in activities that are
associated with Utilization Management, Care Management, and Appeals and
Grievances Management. Medical directors are decision-makers for
medically-necessary as well as non-covered procedures, medications, and
referrals. The medical director might provide direction and guidance,
as well as being a consultant to the care manager. The medical director
roles can also be specialized for management of specific programs, for
example, Cardiac, Diabetes, and Oncology. Primary Portal: CMF Manager Portal Care Coordinator A non-clinical user who is responsible for follow-up calls,
scheduling or running the assessments, visit planning, and case
conference planning and participation. Primary Portal: UM Service Coordinator Portal UM Coordinator A non-clinical user who provides support to members. The UM
Coordinator handles the case triage, establishes visits, performs
scheduling, provides intake to UM activities, and provides non-clinical
assessment (most often around discharge check-in, or low-level
alerts. Primary Portal: UM Service Coordinator Portal UM Manager A clinical user who is responsible for conducting reviews of UM
activities (Prior Auth, Admission, and initial and concurrent reviews).
The UM Manager communicates with providers and facilities about required
data and provides discharge planning for admission cases and transition
to the care manager. Primary Portal: UM Service Manager Portal Administrator A system administrator or business analyst who is associated with
system set-up, flow design, assessment-authoring, report design, and
generation and implementation of care management activities (care plans,
problems, and goals. Primary Portal: Designer Studio Customer Support User A call center representative who is responsible for taking inbound
and outbound calls from or to patients for non-clinical tasks. Primary Portal: CPM Interaction Portal Customer Support Manager A call center manager who keeps track of volume of calls in a day and
performance of the agents. Primary Portal: CMF Manager Portal
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