Working Smarter: How Automation and Decision Intelligence Can Transform Pharmacy Claims Management Workflows
Claims professionals have more on their plate than ever before, juggling complex decisions that impact patient care, cost efficiency, and regulatory compliance. With labor shortages and administrative burdens growing, leveraging automation and decision intelligence is no longer just an option—it’s a necessity.
From day-to-day, overall claims management to treatments to authorizing medications, there are a wide array of increasingly complex decisions that claims professionals in these roles need to make. Fortunately, across a wide range of applications, technology and automation have tremendous potential to streamline workflows and improve efficiency.
How to automate pharmacy claims processing workflows
Artificial intelligence (AI) and predictive models can help claims professionals make quicker, more accurate decisions. However, for these technologies to be effective, companies need to gain a deep understanding of the challenges these professionals face.
“It’s imperative to know the day-to-day responsibilities of a claims professional inside and out to identify the time-consuming efforts that automation and intelligent decision-making processes can address,” says Hollie Lamboy, MyMatrixx Senior Vice President of Product Development.
Once that understanding is established, companies can take the following actions to automate and improve their claims processing workflows:
Optimize prior authorization processes through decision intelligence
Medication prior authorization review is critical to ensure that an injured worker is receiving the drug therapy they need. However, manual review processes can be time-consuming and inefficient.
Applying decision intelligence to this process would mitigate the need to sift through lines of data and extensive amounts of information, enabling faster review or even completely automating review in some cases. More timely completion of prior authorization means reduced administrative burden, greater operational cost savings and a better patient experience.
Leverage advanced clinical analytics
Claims professionals are entrusted to make key decisions multiple times a day that affect the length, cost and medical outcome of an injured worker’s case. A claims professional may need additional clinical insights to make an informed decision, but making sense of all this data is a different story.
Lamboy explains, “By focusing on process automation through the lens of decision-making intelligence, we can present meaningful and actionable data to a claims professional to improve their workflow efficiencies.”
MyMatrixx’s advanced clinical analytics product, CARE, delivers powerful insights about an injured worker’s current and future pharmacy therapy. CARE identifies potentially dangerous drug utilization patterns such as opioid and benzodiazepine use, as well as many other pharmacy risks that may otherwise go unnoticed.
How MyMatrixx by Evernorth supports smarter claims processing
“At the end of the day, technology and automation can transform these workflows in a way that helps claims professionals grow their role so injured patients can have a better outcome,” says Lamboy.
Discover how Clinical and Business Intelligence solutions from MyMatrixx can streamline your claims strategy while promoting the safety and recovery of injured workers—contact us today to learn more.