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Claims examiner

Updated on December 10, 2021

The primary user of the Smart Claims Engine is the claims operations team that utilizes the claims examiner portal.

The claims examiner portal dashboard displays four information panes for quick access.

  • To do list – claims and other cases in examiner’s work queue
  • Recent & Following – recent claim examiner cases and cases that the examiner is tracking
  • Team members – members of claim examiner’s team
  • Notifications – broadcast messages for examiner

The core function of the claims examiner is to resolve suspended claims. The SCE utilizes the urgency algorithms in the Pega Infinity platform to prioritize the work for the claims examiners. The SCE then provides the examiner with the guided event resolution capability to enable suspended claims to be resolved efficiently.

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