Pega Smart Claims Engine for Healthcare supports key roles associated with your day-to-day use of the application. The table below describes the key access roles provided with the Pega Smart Claims Engine for Healthcare.
Role Description Claims Examiner (regular, senior and junior) The claims examiner roles are responsible for resolving suspended
claims and other key operational tasks. Different functionality is
provided for the different levels of claims examiner role. The
claims examiner portal is available for these roles. Claims Manager The claims manager is responsible for managing claims examiners
and team performance, ensuring that examiners meet their SLAs and
KPIs. Dashboards are available on this portal showing work
statistics and other data points. The claims manager portal is
available for this role. Business Analyst The business analyst is responsible for the configuration of the
system, including event codes, action codes, matching criteria and
subsequent testing. The business analyst portal is available for
this role. System Manager The system manager is responsible for approving system
configurations and ensuring that the system is performing correctly.
Dashboards are available on this portal to show the performance of
the system and the file intake statistics. The system manager portal
is available for this role. Test Analyst The test analyst is responsible for testing the claims engine to
ensure that everything configured works correctly. The test analyst
portal is available for this role.