To support claims and claims inquiry routing and review in Pega Smart Claims Engine for Healthcare (SCE), two models are implemented. The first is work queue-based routing, which controls where work items are routed. The second is skill-based routing, which filters the type of work an individual can retrieve from the work queue. Pega Smart Claims Engine for Healthcare provides configurations for skills-based routing for both claims and claim inquiries.
The retrieval of work by using skill-based routing enables efficient routing of claims or claim inquiries only to claims examiners who have the appropriate skills. This improves operations by ensuring that the right operator can always work on the right piece of work.