Operations Transformation
Strategic Initiatives for Operational Excellence
Intelligent automation and unified platforms across Claims, UM, and Member Services
Executive Summary
Prioritized topics driving operational excellence and digital transformation
| Focus Areas | Status |
|---|---|
Claims - Digital Sorting Scan mail at receiving location as first step, perform automated machine sorting on digital copies for 90%+ claims, provide advanced UI for exception scenarios where human interventions are required | In Focus |
Claims - Indexing Introduce capture tool with 95% field accuracy (not requiring intervention), remaining 5% handled in advanced UI, replace ImageNet third-party vendor with in-house tooling and offshore indexer staff | In Focus |
Auth & Corro - Digital Sorting Leverage tooling introduced in Claims Sorting (conceptually similar). Replace Macess DocTriage with advanced digital sorting module capable of detecting document boundaries and auto-classifying/routing faxed, mailed, or other source incoming documents | In Focus |
Auth & Corro - Indexing IBML Initiative is already ongoing addressing this automation opportunity. Double-confirm extracted data and perform system lookups (member, provider, auth, eligibility) to ensure documents are properly contextualized before routing | Underway |
Voice-Bots Identify best candidates in terms of call frequency, complexity, and time consumption per communication type, then introduce bot replacements for high-volume routine interactions | In Focus |
IDM Enhancement / Replacement Phased migration to modern correspondence management with template modernization | In Focus |
360 Member View Replace Macess Docviewer with advanced Review tool. Improvement and evolution of in-house tools like Fixer with enhanced capabilities: unified data aggregation layer, in-app pricing calculator, full-text document search, collaborative annotations. Collaborative effort with in-house team to build unified front-end layer | In Review |
Claims - Autoadjudication Execute ML algorithms to find common/correlated properties for claims that are sent to manual adjudication but always approved, then expand auto-adjudication rules based on findings | In Review |
Macess File Cabinet Evaluation Comprehensive capability assessment and gap analysis to understand which Macess features are actively used versus available product capabilities. Evaluate technical debt, integration points, and develop technology roadmap for modernization or replacement options | In Review |
Smart Work Distribution Build intelligent routing engine with granular skill set mapping and workload balancing | In Review |
Misdirected Claims Redesign communication workflows and notification processes for misdirected claims | Underway |
Claims - Digital Sorting
Transform physical mailroom operations by replacing manual human sorting with intelligent digital classification. Scan mail in-house on day-zero and automate 90%+ of sorting work.
Process Transformation
Current Process
Manual, paper-based workflow
Mail Arrival
Physical mail arrives at mailroom
Manual Sorting
Staff manually sort every page by type, member, claim
Insert Separators
Physical separator sheets with control numbers added
Courier Pickup
Physical transport to Imagenet vendor
Vendor Scanning
Imagenet scans, indexes, and keys data
Data Delivery
TIFFs to EDI team, data file to EZ-Cap
Proposed Process
Digital-first, automated workflow
Mail Arrival
Physical mail arrives at mailroom
Instant Scanning
High-speed scanner captures all pages in sequence
Digital Sorting
Software auto-detects boundaries, 90%+ accuracy
Human Review
Staff validate digital sorting on screen
Immediate Transmission
Digital files sent to Imagenet continuously
Data Processing
Imagenet performs data keying only
Interactive Process Canvas
Key Benefits
Reduced Time Spent on Sorting
Staff no longer spend hours manually sorting paper. They simply scan and validate digital suggestions on screen.
Faster Delivery to Imagenet
Documents are scanned in-house and transmitted immediately. No more waiting for daily courier pickup. Continuous delivery throughout the day.
Normal Working Hours
No more early morning wakeups required. Mailroom shift can start at regular business hours since digital processing eliminates courier pickup deadlines.
Foundation for Non-Claims Intake
Sets up the foundation and tooling to improve intake processes for all Non-Claims channels including faxes, digital submissions, and provider uploads.
No Courier Cost
Eliminates direct courier expense and indirect costs of scheduling, coordination, and handling delays. Digital handoff is instantaneous.
No Cost for Separator Sheets
No printing or inserting physical separator sheets. Staff no longer maintain inventory or manage control numbers manually.
Lower Vendor Costs at Imagenet
Imagenet performs only data keying—no sorting, scanning, or batch prep. 60% cost reduction expected.
Better Staffing Flexibility
Digital work can be shifted to other teams or locations. Remote staff can participate in classification. Dynamic reallocation during surges.
Immediate Visibility Into Mail Volumes
Real-time dashboards show mail arrival, document types in queue, and bottlenecks. Eliminates black box period between arrival and processing.
Earlier Start on Downstream Work
Claims, UM, appeals, and provider ops receive documents hours earlier. Improves SLAs and reduces aging backlogs.
Reduced Risk of Lost or Misrouted Mail
Digitizing immediately removes physical handoff risks. Every page is captured, tracked, and audit-ready from day one.
Stronger HIPAA & Security Controls
Mail no longer transported offsite. Access governed through system permissions, audit trails, and automated logging.
Enhanced Disaster Resilience
Digital copies eliminate catastrophic risk of losing irreplaceable physical mail to fire, flood, or other disasters.
Future Automation Pathway
Digital foundation enables future document recognition, ML-based splitting, auto extraction, and auto matching to members and providers.
Phased Execution Roadmap
Step-by-step rollout approach. Start with foundation setup, then deploy iteratively PO Box by PO Box. No big-bang deployment - each step is validated before moving to the next.
Foundation Setup
Setting up integration and scanning routine
Pilot PO Box
First PO Box rollout with highest volume
Iterative Rollout
Expand PO Box by PO Box
Claims - Indexing
Software tooling for automated claims indexing with human-in-the-loop review. State-of-the-art extraction combined with fast correction UI enables Conifer to outsource or offshore indexing at lower cost with faster processing rates. Integrated lookups validate data early, reducing downstream errors.
The Approach
Current State: ImageNet
- Third-party vendor handles claims indexing
- Limited visibility into process and quality
- Fixed pricing model with vendor dependency
- Evaluate current ImageNet capabilities and costs
Proposed: In-House Software Tooling
- Automated extraction with confidence scoring
- Human-in-the-loop UI for fast review and corrections
- 95% field-level accuracy on average - minimal corrections needed
- Flexible outsourcing or offshoring options
- Full control over quality and costs
How It Works
1. Document Arrives
Digitally sorted claim enters queue
2. Auto-Extraction
System extracts all fields
3. Integrated Lookups
Member, provider, auth, dup checks
4. Field Validation
95% fields correct on avg
5. Human Review
Fast correction UI (if needed)
6. EZ-Cap Ready
Data populates claim record
Early Error Detection with Integrated Lookups
Data validation happens early in the indexing process, catching errors before they propagate. Unlike the current ImageNet setup where Conifer must fix vendor errors downstream, issues are addressed at the source—reducing complexity, rework, and downstream processing delays.
Field-level accuracy (avg)
Fields needing correction
Extraction Fields Overview
Member Info
- Member ID
- Name
- DOB
- Group Number
Provider Info
- Provider NPI
- Facility Name
- Tax ID
- Address
Claim Details
- DOS
- Billed Amount
- Procedure Codes
- Diagnosis Codes
Document Meta
- Document Type
- Page Count
- Received Date
- Source Channel
Key Benefits
State-of-the-Art Extraction Engine
Modern extraction technology identifies and captures key data fields with high accuracy, reducing manual indexing effort.
Human-in-the-Loop Review UI
Intuitive correction interface allows reviewers to quickly validate and fix extraction results. Only claims needing human touch are surfaced.
Integrated Lookups During Indexing
Member, provider, authorization, and duplicate/corrected claims lookups happen early in the process. Issues are caught and returned to indexers for immediate correction instead of Conifer fixing vendor errors later.
Faster Indexing Rates
Automated pre-extraction combined with streamlined review reduces per-claim indexing time significantly.
Lower Indexing Costs
Software tooling enables Conifer to outsource or offshore claims indexing at reduced cost while maintaining quality.
Outsourcing & Offshoring Ready
Web-based tooling can be deployed anywhere, enabling flexible workforce options and cost optimization strategies.
Quality Control Built-In
Confidence scoring, exception routing, and audit trails ensure accuracy regardless of where indexing is performed.
Expected Outcomes
Cost Reduction
Via outsourcing/offshoring
Extraction Accuracy
For all fields on average
Less than 5% Fields Need Intervention
Minimal human touch
Phased Execution Roadmap
Deploy extraction tooling, validate with pilot batches, then scale to enable outsourcing and offshoring.
Tooling Setup
Pilot & Validation
Scale & Optimize
Claims - Autoadjudication Improvement
Leverage data extracts from EZ-Cap to detect patterns in non-autoadjudicated claims. Identify claims that are consistently untouched during processing and safe to add to the auto-pass set, increasing straight-through processing without compromising accuracy.
The Opportunity
Current State
- Conifer has improved autoadjudication rates through constant evolution and scripting
- Current approach relies on examiner experience and report analysis
- Manual scripting has natural limits in discovering hidden patterns
- Opportunity to go further with data-driven pattern discovery
Proposed Approach
- Find correlations based on evidential facts in EZ-Cap data
- Different approach: let data reveal patterns, not manual scripting
- Shadow test before enabling new autoadjudication rules
- Gradually expand auto-pass set with continuous monitoring
How It Works
1. Data Extract
Pull claims history from EZ-Cap
2. Identify Patterns
Find untouched claim characteristics
3. Shadow Test
Validate predictions on live claims
4. Expand Rules
Enable new auto-pass criteria
5. Monitor
Continuous accuracy tracking
Claims Characteristics
- Claim type & subtype
- Provider specialty
- Service codes
- Diagnosis combinations
Processing Outcomes
- Touch count (zero/one)
- Adjustment patterns
- Denial rates
- Processing duration
Historical Behavior
- Provider payment history
- Member claim patterns
- Contract terms alignment
- Pricing consistency
Data Quality Indicators
- Field completeness
- Code validity
- Eligibility match rate
- Authorization presence
Key Benefits
Increased Straight-Through Processing
Expand auto-pass claim set by identifying claims that consistently process without manual intervention.
Reduced Manual Touch
Focus examiner effort on complex claims that truly need human judgment, not routine claims stuck in queues.
Data-Driven Decision Making
Pattern analysis provides evidence-based criteria for expanding autoadjudication rules, not guesswork.
Risk-Controlled Expansion
Gradual rollout with continuous monitoring ensures accuracy is maintained while throughput increases.
Measurable Impact
Clear metrics on claims migrated, touch reduction, and processing time improvement track ROI.
Transparency & Auditability
Every auto-pass decision is logged with the pattern criteria that qualified it for expanded processing.
Phased Execution Roadmap
Extract data, analyze patterns, validate in shadow mode, then gradually expand autoadjudication rules with continuous monitoring.
Data Extraction & Analysis
Pattern Validation
Controlled Expansion
Non-Claims - Digital Sorting
Unify intake for authorizations, correspondence, and medical records across all channels—fax, mail, email, and portal uploads. Replace Macess DocTriage with a single intelligent platform.
Unified Intake Channels
Fax Lines
Inbound faxes from providers and plans
Physical Mail
Non-claims correspondence and documents
Digital submissions and attachments
Provider Portal
Uploaded authorizations and records
Document Types & Routing
Authorization Requests
Medical Records
Provider Correspondence
Member Communications
Appeal Submissions
Clinical Documentation
Key Benefits
Unified Intake Pipeline
All non-claims documents flow through one platform regardless of source—fax, mail, email, or portal upload.
90% Automated Routing
Intelligent classification routes documents directly to IBML without manual intervention for most cases.
Replaces Macess DocTriage
Consolidates functionality into the unified platform, eliminating redundant systems and licensing costs.
Reduced Manual Effort
Staff focus on exception handling rather than routine classification and routing tasks.
Faster Processing
Documents reach UM, Case Management, and Provider teams same-day instead of next-day.
Consistent Handling
All channels processed with identical rules, ensuring uniform quality and audit compliance.
Phased Execution Roadmap
Incremental rollout by fax line, mail channel, and document type. Parallel running with DocTriage during validation.
Foundation
Weeks 1-4
Expansion
Weeks 5-8
Scale
Weeks 9-12
Unified 360° Member View
A single, unified review and inquiry interface providing a complete view of each member across Claims, UM, Case Management, and Provider Engagement teams
The Challenge Today
Team members must open and cross-reference several systems—EZ-Cap, Macess, CAP Connect, benefit guidelines, CMS pricing tools, pharmacy calculators, immunization portals, and provider directories—just to assemble basic context around a claim or authorization. This fragmentation slows down processing, creates inconsistent results, and forces teams to repeat the same work.
Unified Layer Architecture
Front-end layer retrieving information from multiple systems into one structured view
360° Member View
Unified Front-End Layer (Read-Only Initially)
Key Capabilities
Multi-System Aggregation
Single workspace displaying claims, auth data, images, benefit rules, pricing, pharmacy calculations, and provider lookups
- Claims and auth data from EZ-Cap
- Images and correspondence from Macess
- CMS pricer data (no manual website navigation)
- Pharmacy dosage/unit calculations
- Immunization history
- Document-based duplicate/overlap detection
Modern Image ↔ Data Review
Link system fields directly to highlighted areas on scanned documents
- Field-to-document highlighting
- Grouped related fields
- Visual cues for faster checking
- Text search on images
- Predefined quick searches (EOBs, UB04, medical records)
Natural-Language Inquiry ("Ask the Document")
Staff can ask questions directly against document content
- "Where is the discharge date?"
- "Show me all diagnoses mentioned"
- "Highlight medications"
- Results highlighted in document viewer
- Especially helpful for non-standard documents
Team-Specific Modules
Shared interface with specialized capabilities for each team
- Automated unit and dosage calculator
- Allowed vs billed amount comparison
- Key financial field highlighting
- Direct policy/guidelines access
- Eligibility checks
- Historical auth connections
- Consolidated patient history
- Immunization data integration
- Standardized care goals/letters
- Provider lookup
- Facility contact information
- Network/contract status
Incremental Delivery Approach
This tool can be delivered in small, manageable steps, where additional features in the viewer are added one by one—allowing the organization to introduce value quickly, validate each improvement, and expand capabilities gradually without a large disruptive overhaul. Initially read-only, with optional expansion later (notes, tasks, or selected field edits to EZ-Cap).