Agenda & Introductions
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3 Agenda & Introductions About WellCare, Virtusa Overview of Complaints, Appeals and Grievances (CAG) Program Our Challenges and Pega Solution Solution Vision & Capabilities Our Accomplishments and Keys to Success Leon Sabarsky Director IT, WellCare IT Sponsor Baskar Mohan Director Healthcare Practice, Virtusa Engagement Lead 3
4 About WellCare WellCare Health Plans, Inc. provides managed care services targeted to governmentsponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. A Fortune 500 and Barron s 500 company, NYSE: WCG Employs approximately 6,700 associates nationwide Serves approximately 4.1 million members Provides access to 348,000 contracted health care providers Provides access to 77,000 contracted pharmacies 4
5 About Virtusa WHO WE ARE Global IT Services Provider Headquartered in Westborough, MA Locations in US, Europe, Asia and Middle East Technology Centers in U.S., U.K., Hungary, India & Sri Lanka Over 9000 world-class professionals 112 active clients Listed on NASDAQ (VRTU) Rapid and profitable growth FY 2014 revenue: $396.9 million Operating income: $42.4 million 10-year revenue CAGR: 24.94% Numerous industry awards and certifications Platinum Partnership Snapshot Pega Platinum Partner with 14 years experience 1,000+ Pega Consultants deployed worldwide Pega authorized V7.1 upgrade partner Long established Pega engineering partner with current focus on PCS Winner of Pega awards Pegasystems Partner Excellence Award Thought Leadership in Legal Services Pegasystems Partner Excellence Award Excellence in Solution Delivery
6 Overview of the Program Background WellCare s Appeals & Grievance project intends to build a single, unified platform for processing Complaints, Appeals and Grievances (CAG) for WellCare customers Program Mandate Provide a single, unified platform for processing Complaints, Appeals and Grievances (CAG) Increase enterprise reporting accuracy and data consistency with consistent processes and data elements Improve ability to adhere to internal and external Service Level Agreements (SLAs) Capture cost savings from reduced financial and legal exposure Decrease training time for new CAG coordinators by providing an intent-driven PRPC-based process Establish data to support internal & external audit responsibilities 6
7 Key Business Challenges Lack of BPM Implementation experience within the organization Infrastructure setup to handle multiple projects Concurrent projects with significant dependencies Pressure to act Training for new users Existing traditional Waterfall methodology Enterprise need for a unified BPM Platform 7
8 Why Pega? Enterprise business rules and work flow application Provides Omni channel experience across all applications Speed to market Why Pega? Automation of Manual Processes and Routing Business drives change Pega 7 - Care Management & Appeals and Grievances application 8
9 The Virtusa Way with Pega Solution Provider Info Provider Contracting Provider Credentialing Par/ Non Par Provider Disputes Provider Details CTM PCTM Inquiries Appeals Grievances Member Contact Info Policy Details Preferred Communication Channel Authorized Reps Inpatient Outpatient Pharmacy DME Dental Vision Member Profile Claims Authorizations Appeals & Grievances Enrollment Inpatient/Outpatient Referrals DME Prescription Drugs Medicare Medicaid HIX PDP Wellness CM/DM 9
10 Salient Capabilities Automatic creation of cases against the complaints registered with CMS Updating existing cases with information received from CMS Intelligent routing of cases based on agent availability, skill and work load Issue-based branching and routing of cases Updating internal/external systems with the status of cases in real-time Quality assurance review of the resolution provided to the issues SLA-based escalations/notifications to teams and supervisors, and complainant Insights into agent operations, allowing WellCare to identify and address bottlenecks 11
11 Realized Results 125 use cases built in just 10 weeks 60% re-usable functionality More than 50 users have been trained High user satisfaction Increase in productivity Robust Reporting 11
12 Agile Delivery for Business Transformation 12
13 Our Key to Success Better manage application installations Focus on User experience Pre-plan testing with CMS and other external stakeholders Multiple demos to the business users 13
14 Q & A
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