Guided Process for Case Processing and Compliance

Health Insurance Provider — Claims, Appeals & Grievances

Naaja King
6 min readSep 28, 2017

Project Overview

As part of business and technology transformation initiative, the Appeals &Grievances (A&G) department replaced outdated and unsupported component content management system with the more agile and capable PegaRULES Process Commander platform to enable a more efficient Appeals & Grievances process. The new A&G platform was implemented in multiple phases, with each phase enabling complete A&G capabilities with automation aligned with specific organizational lines of business.

Challenge: The department was tasked to reduce the labor cost for case processing and administrative managerial cost to oversee operations while maintaining the quality and consistency necessary to avoid of non-compliance penalties.

Opportunity: Guided process to standardize and simplify tasks such as Identifying duplicate cases. The new system provided an opportunity for processes improvements such as distributing work more effectively through automation. The new system also allowed the organization to incorporate more analytics and reporting to provide visibility into case data and workload reporting.

Goal: A guided process of standardized and repeatable steps for A&G resolutions would begin with gathering and standardizing the most important information at the initial point of contact. The information would be documented in an audit trail would further the organizational goal of focusing on their customer needs by providing the best resolution without the need to rework the case. The guided process would also facilitate the adherence to the strict Service Level Agreement (SLA) necessary for compliance.

My Responsibilities: As the UX Lead, I was responsible for guiding the design process from start to finish, As a client liaison I worked closely with the project sponsors and subject matter experts to insure that the user experience met the needs of the various user groups while aligning with the organizational business objective. This ranged from conducting user interviews to producing all design deliverables including: personas, user flows, wireframes, high-fidelity mockups, journey maps, and the style guide


The first phase of the project began by interviewing the business stakeholders the identifying the various user groups to interview.

User Research

Through our initial interviews with the department stakeholders and business sponsors, we identified 5 distinct groups within the department.

We interviewed 18 users out of the department of 67 people for a total of almost 24 hours worth of interview footage:

  • 5 Clerical Users
  • 4 Managers
  • 3 Resolution Specialists
  • 5 Non-Clinical Specialists
  • 1 Clinical Specialists
Contextual Inquiries: We watched 4 different user groups performing their typical daily tasks, both in person and through screen sharing.

We found that the Clinical Users had a unique set of needs that were already being met by a third party medical records system. They only used the CCMS system to enter in their final appeal determination, while the other 4 groups used the CCMS system while gathering information from up to four other systems that did not talk to each other. This led us to concentrate our focus primarily on 4 out the 5 groups with the A&G department.

Process Flows

The steps taken to complete the processing of a case within the current process were documented. This helped identify areas for improvement within the existing process. The User flows were developed to illustrate how the different user groups accomplish their tasks within the current system.

Research Findings

Based on the qualitative data gathered we gained valuable insights into the behaviors and frustrations based on observing the users directly as they performed their daily tasks. We looked at the most common frustration to gain understanding into how the application could make the process more efficient and effective.


The research findings were synthesized to determine the tasks that were most important in order to accomplish the goal of processing A&G cases quickly while meeting compliance standards.


Our research centered on the 4 out of 5 user types that would be using the application the most. Lean, role-based personas were developed focusing on the user’s function and responsibilities within the department. Since the goals of the user groups were aligned with different stages in the Case Processing life cycle, a case processing life cycle was developed to map the user goals against. Basic demographic information such as years of experience and work location/environment was included to provide insights into the needs of each group.

Feature Prioritization

The personas helped to uncover universal used features and functionality, as well as aid the evaluation of new ideas. Those insights were important in determining which features made the most sense to recommend for implementation.


We made a plan for how we could make the application user friendly while retaining the depth of information needed at various points in the process.

Design Enhancements

Depending on the case, a user might need to see only the most recent data or historical data sometimes going back multiple years. A strong focus on the visual hierarchy and placement of data and tools was important so that they user had access to multiple layers of data when it was required without cluttering the screen when it was not necessary.


We were able to streamline the A&C case process while guiding the user through their tasks with structured forms, context specific searches, and reminders within a persistent workflow structure.

Annotated Wireframes

The annotations indicate details that are not easily discerned from a static wireframe. This includes functionality, user interactions, and explanations of the content. The goal was to communicate to business analyst, developers and client the value of the design in the context of the bigger picture of how the application would contribute towards established KPIs.

Style Guide

The style guide is a “living document” to promote reusability for the current and future applications that catalogs of all the repeating visual patterns in order to maintain visual consistency. Designers and developer were able to save time by using the style guide as a reference instead of starting from scratch each time.

Next Steps

  • Conduct Usability Testing on the application once it’s released
    Gather insights on learnability, memorability, errors and satisfaction
  • Include responsive layouts for other sizes for future technologies
    The initial application was developed specifically for the 1366x768 screen resolution size, based on the standard monitors for the office and company distributed laptops
  • Increased Functionality
    Some features were not implemented despite the benefit to Users due to time and budget constraints. In the future, those features could be re-visited
  • Increased Integration
    The first release was scoped to include integration with 2 existing portals, 4 system integrations. Additional medical records system integration would allow Clinical Users to migrate to the new application.