The Human Side of Workflow Tech: Claims + Enrollment

Claims and enrollment management can feel like a juggling act, especially with rising volumes and the pressure to meet strict accuracy and timeliness standards. What if there were tools to simplify it all? In this episode, we dive into the game-changing power of modern workflow solutions. Discover how these tools eliminate inefficiencies, prevent cherry-picking by claims and enrollment processors, and streamline auditing, all while boosting internal team communication and productivity. Whether your health plan claims and enrollment teams are struggling with manual processes or looking to scale without adding staff, this discussion offers practical insights you can’t afford to miss. Tune in to learn how to transform your claims and enrollment management strategy!

Host: Today’s episode is all about workflow management tools and how they’ve become a game-changer in claims and enrollment processing. If you’ve ever wondered how technology tools can make a big difference for streamlining claims and enrollment processing, reducing errors, and boosting productivity, you’re in the right place.

Joining me is Alison South, the Vice President of revenue enablement and a subject matter expert in payer technology and operations. She brings 20+ years of experience in health plan operations, overseeing operational readiness, learning and development, and quality and audit operations. She has worked for large national payers running government programs, including Medicare and State Medicaid Demonstration programs and military healthcare operations. Alison, welcome to the show!

Alison: Thanks for having me! I’m excited to discuss the latest workflow tools for supporting claims and enrollment processing.  

Host: Let’s start at the beginning. What did workflow management look like in claims and enrollment processing prior to technology?  

Alison: From the claims perspective, claims processing can be chaotic. Claims examiners typically work from work baskets filled with claims. But here’s the catch—without a system to prioritize or automate the order, they can pick and choose which claims to process. That means complex or time-consuming claims often get ignored in favor of easier ones, a practice called ‘cherry-picking.’ Managers often resort to using Excel spreadsheets to manually assign claims. They email these spreadsheets back and forth to track progress. Not only is this cumbersome, but it’s prone to human error, such as missing claims, having miscommunications, or delaying processing. Overall, it’s pretty inefficient and frustrating for everyone involved.

Host: Wow, that sounds like a logistical nightmare. What are the implications of these inefficiencies for health plans and their members?

Alison: The biggest issue is timeliness. Industry standards require clean claims—those that don’t need additional information—to be processed within 30 days. All claims need to be resolved within 90 days. Without an effective workflow system, meeting these benchmarks can be challenging. Delays hurt members waiting for claims to be processed and impact the financial health of the plan itself. Additionally, without proper workflow tools, there’s a lack of transparency into productivity and quality. Managers can’t easily see who’s processing claims, how long it’s taking, or whether errors are creeping in. Then, there are communication barriers between processors and auditors with emailing back and forth rather than working in one cohesive system.  

Host: Got it. Now, let’s flip the script. What does this process look like with a robust workflow management tool in place?

Alison: It’s a lot different with technology. With advanced workflow tools, claims are automatically queued and assigned to examiners based on criteria like age, complexity, or skill level. This removes selection bias and ensures that claims are processed in the proper order—first in, first out.  

It’s important for payers to move towards automation for auditing samples of claims, the presentation of the claim to the auditor, the automation of the checklist that’s used to audit the transaction, the feedback between the auditor and the processor should be automated, and the tracking of whether or not the examiner has responded to the auditor and agrees or disagrees with the auditor. This should all occur within one, seamless technology platform.

For managers, real-time dashboards provide transparency into productivity and inventory. They can see which claims are being worked on, how long each examiner takes, and where bottlenecks might occur. If one examiner finishes their workload early, managers can dynamically reassign claims to balance the workload across the team.  

Another important note is that all of these same process improvements we’re discussing here today can be applied to enrollment transactions too. That’s what UST HealthProof’s workflow tool does—it improves processing for both claims and enrollment records. 

Host: Good to know. All of this sounds like a huge improvement on the manual workflow that is pieced together and held by duct tape. What about the auditing process? How do these tools streamline that?

Alison: Great question. Auditing is a critical part of claims management. Advanced tools automate this process end-to-end. They sample claims for auditing, present them to auditors, and provide checklists to ensure compliance with financial and procedural accuracy standards.

If an error is found, auditors can attach resources like standard operating procedures, or desk level procedures, to show how the claim should’ve been processed. This feedback loop happens within the same system, so examiners don’t need to leave the platform or rely on email. It saves time, reduces errors, and ensures compliance with regulatory standards.

Host: Let’s shift gears a bit and talk about scalability. Many health plans are dealing with growing claim volumes and tighter budgets. How do these tools help organizations scale effectively without increasing costs?

Alison: That’s an important consideration. Workflow tools are designed with scalability in mind, which means they can handle increasing workloads without requiring proportional increases in staff or resources. For example, as claim volumes grow, the automated assignment and prioritization feature ensures that work is evenly distributed and processed efficiently. These tools also help organizations avoid costly hiring spikes by maximizing the productivity of existing staff. Features like productivity tracking allow managers to identify underutilized capacity and optimize their teams. Another key factor is error reduction. Errors in claims processing can lead to costly rework, delays, and potential financial penalties for failing to meet accuracy standards. By automating repetitive and error-prone tasks, workflow tools significantly reduce those risks, which translates into staff time being used effectively. So, yes, these tools can certainly help adapt to organizational growth.

Host: Ok. Let’s talk metrics. What key performance indicators should health plans be tracking to enhance the claims process, and how can technology enhance these metrics?  

Alison: So the big one is claims processing timeliness. As mentioned earlier, claims must be processed within 30, 60, or 90 days, depending on their type and complexity. Workflow tools track these deadlines, flag delays, and push timeliness. And then accuracy is another big KPI, typically we like to see 98.5-99% accuracy to ensure claims are paid correctly. We like procedural accuracy to hang around 98.5% and check that claims are processed according to policy. Workflow tools help achieve these high benchmarks by minimizing manual errors and providing built-in auditing capabilities. Again, we do a lot of configuration work up front and then continually refine it over time, so it’s a constant effort between our configuration team and clients. We’re always aiming to improve. So, I would say these are the top metrics for health plans to operate efficiently, meet service-level agreements, and avoid penalties.  

Host: What about internal metrics?  

Alison: The important internal metrics plans need to be looking at include standards of productivity to assess the skill sets of claims processing teams, productivity standards for auditors to assess the average complexity of the claim or enrollment record, assessing the experience level of staff. It’s important to be able to measure this so you can do more with less staff.

Host: Let’s make this relatable. Can you walk us through a day in the life of a claims processor using a workflow tool?  

Alison: Sure. Let’s say a claims examiner logs in at the start of their shift. Their dashboard immediately displays their queue, showing the next claim they need to process. The system has already prioritized the queue by age and complexity, so they don’t have to decide which claim to work on next. As they process claims, a timer tracks their productivity, giving both the examiner and their manager visibility into how they’re performing. If they get stuck on a complex claim, they can flag it for review, and a team lead can reassign it to someone with the necessary expertise. Meanwhile, managers are monitoring productivity in real-time. For example, they might notice that one examiner is ahead of schedule and reassign some claims from a busier teammate. This ability to dynamically balance the workload keeps the entire team running efficiently.

Host: That’s a great visualization. Let’s talk about the future. Where do you see workflow tools evolving in the next few years?

Alison: The future is all about integration and AI. Advanced tools are already using AI to predict workloads and proactively assign resources. For example, based on historical data, the system can predict when claim volumes will spike and preemptively reassign staff or alert managers to prepare. We’re also seeing more integration across platforms. For UST HealthProof, instead of jumping between systems for claims, auditing, and reporting, everything lives in a single, unified platform. This further reduces errors, improves user experience, and increases productivity.

Host: This all sounds fantastic, but let’s talk about the human side of things. Introducing new technology can sometimes face resistance from staff. How do you ensure a smooth transition when implementing workflow tools?

Alison: That’s a great point. Change management is critical when rolling out new tools, especially in industries like healthcare, where teams are accustomed to established processes. A smooth transition starts with strong leadership. Managers need to communicate the ‘why’ behind the change—how it’s not just a new tool, but rather, a way to reduce frustration, save time, and improve accuracy. Training is another essential piece. Workflow tools should be intuitive, but we also need to provide hands-on training that allows users to become comfortable with the platform. These sessions often include real-world scenarios so staff can see how the tool fits into their daily tasks. We’ve also found that early wins can make a huge difference. For example, within the first few weeks of implementation, managers might highlight how the tool eliminated manual spreadsheet tracking or saved hours of work by automating claim assignments. Sharing those wins in team meetings builds trust in the tool’s value.

Host: I imagine the shift also brings benefits for staff, not just the organization. What’s in it for them?

Alison: For claims examiners, the tool removes a lot of the manual work, like searching through a queue or managing email requests. They can focus on the core task of processing claims without distractions. For managers, it simplifies oversight, giving them more time to support their teams. Ultimately, the tool makes everyone’s job easier while reducing burnout and increasing job satisfaction. When teams see those benefits, adoption naturally follows.

Host: Exciting times ahead! Alison, thank you so much for sharing your expertise today. This has been an eye-opening conversation about the power and necessity of workflow tools for claims management.

Alison: Thanks for having me! It was a pleasure to chat with you.

Host: And thank you to our listeners for tuning into Current Trends for Payers. If you found this episode helpful, be sure to follow on Apple or Spotify, and share this episode with your colleagues on LinkedIn.