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Skill-based routing

Updated on June 16, 2021

The Pega Smart Claims Engine (SCE) for Healthcare 8.7 release introduces skills-based routing capabilities so that claims and inquiries are retrieved by claims examiners with the most relevant skills. Based on SCE rules and configuration, the skills-based routing capability stamps the claims (or claims inquiries) with the skills needed to resolve them.

This results in efficient claims and claims inquiry resolution as SCE matches the stamped skills with the skills configured on the claims examiners operator record. SCE provides various out of the box skills (claim type, line of business, high dollar, member, authorization, COB, etc.) which can be assigned to users, claims, and claims inquiries.

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