Improving the QA Experience for Healthcare Claim Reviewers
Improving the QA Experience for Healthcare Claim Reviewers
Improving the QA Experience for Healthcare Claim Reviewers
Product Design
Product Designer
Product Design
Heather Cooper and Shanu Padmanabhan
Responsibilities
Product Designer
Responsibilities
Research, Information Architecture, Persona Development, Design Strategy, Wireframing, Prototyping
Timeline
Product Designer
Timeline
6 Months
Context
Context
Context
Healthcare claims auditing is a complex and and high-stakes process. Every reviewed claim has financial impacts across payers, providers, and members. The audit QA team is responsible for checking the work of the initial auditors to ensure there were no errors and nothing was missed. Their work ensures compliance with Centers for Medicare & Medicaid Services (CMS). But, the system they rely on is scattered across legacy applications, spreadsheets, and emails. QA Managers must make sure initial auditors have at least 10% of their claims QA’d each month, but they are tracking these assignments by memory and manual calculations. QA Auditors experience overly-complicated check-out processes. Simple tasks become slow and error-prone.
Our goal is to redesign the entire QA workflow into a single, intuitive experience that supports both the QA Managers and QA Auditors.
Healthcare claims auditing is a complex and and high-stakes process. Every reviewed claim has financial impacts across payers, providers, and members. The audit QA team is responsible for checking the work of the initial auditors to ensure there were no errors and nothing was missed. Their work ensures compliance with Centers for Medicare & Medicaid Services (CMS). But, the system they rely on is scattered across legacy applications, spreadsheets, and emails. QA Managers must make sure initial auditors have at least 10% of their claims QA’d each month, but they are tracking these assignments by memory and manual calculations. QA Auditors experience overly-complicated check-out processes. Simple tasks become slow and error-prone.
Our goal is to redesign the entire QA workflow into a single, intuitive experience that supports both the QA Managers and QA Auditors.
Healthcare claims auditing is a complex and and high-stakes process. Every reviewed claim has financial impacts across payers, providers, and members. The audit QA team is responsible for checking the work of the initial auditors to ensure there were no errors and nothing was missed. Their work ensures compliance with Centers for Medicare & Medicaid Services (CMS). But, the system they rely on is scattered across legacy applications, spreadsheets, and emails. QA Managers must make sure initial auditors have at least 10% of their claims QA’d each month, but they are tracking these assignments by memory and manual calculations. QA Auditors experience overly-complicated check-out processes. Simple tasks become slow and error-prone.
Our goal is to redesign the entire QA workflow into a single, intuitive experience that supports both the QA Managers and QA Auditors.
Discovery
Discovery
Discovery
At the start of the initiative, we conducted a series of collaborative sessions with the business team, QA managers and QA auditors to gain an in-depth understanding of the QA process, user workflows, and the unique challenges involved. Through demos, workflow reviews, and detailed discussions, we identified inefficiencies, platform limitations, outdated QA questions, overly-manual processes, a convoluted claim check-out process, and the burden of navigating multiple legacy systems and external spreadsheets.
Platform Limitations
Platform Limitations
Error-Prone Workflows
Limited Visibility and Functionality
Cluttered and Outdated Interface
Error-Prone Workflows
Limited Visibility and Functionality
Problem Statement
QA managers and auditors need a more efficient way to track, calculate, assign, and review healthcare claim audits so that they can maintain accuracy and quality standards, ensure compliance with CMS requirements, and identify all potential recoveries to maximize revenue opportunities.
Problem Statement
QA managers and auditors need a more efficient way to track, calculate, assign, and review healthcare claim audits so that they can maintain accuracy and quality standards, ensure compliance with CMS requirements, and identify all potential recoveries to maximize revenue opportunities.
Users
Solution
Users
We focused on two primary personas, the QA Manager and the QA Auditor. Over the hours of observing these users, we learned most of them have been in the work for twenty plus years. They developed individual and unique workarounds to account for the fragmented nature of the current state. Instead of ignoring those patterns, we designed with them in mind. Our goal was to streamline the experience while supporting the task flows they rely on every day.
The GSAT QA redesign was our chance to untangle a process that had been held together by memory, spreadsheets, and years of personal workaround habits. We set out to replace that patchwork with a single, coherent system built around how QA managers and auditors actually work.
The new tool brings claim assignment, review, scoring, and tracking into one place. QA managers can finally see workload, performance, and compliance metrics without juggling files or relying on what they can remember. QA auditors no longer jump between tools. They can check out a claim, review the initial audit, and complete their assessment in one flow. The dynamic QA form supports accurate reviewing.
Every decision in the redesign came from watching users navigate the old system. The result is a workflow that removes friction and gives the QA team a more dependable way to do their work.
Problem
Statement
QA managers and auditors need a more efficient way to track, calculate, assign, and review healthcare claim audits so that they can maintain accuracy and quality standards, ensure compliance with CMS requirements, and identify all potential recoveries to maximize revenue opportunities.
Cluttered and Outdated Interface
Error-Prone Workflows
Limited Visibility and Functionality
Information Architecture
Information Architecture
Insights from user interviews allowed us to identify key user needs and priorities. We then created and used the sitemaps to prioritize critical task flows such as reviewing profiles, assigning claims, checking out claims, and conducting QA reviews.
Low-fidelity
Low-fidelity
We started with low-fidelity wireframes to map out how QA managers and auditors move through their most essential tasks. Keeping things simple helped us focus on what mattered: the information they need to see, the decisions they make and the steps that define a successful assignment or review. These early sketches gave us space to test ideas quickly and validate with stakeholders, before committing to detailed design.
User Flows
User Flows
Before moving into detailed design, we mapped out the end-to-end workflows for both QA Managers and QA Auditors. These flows helped us understand how these users actually move through their tasks, the decisions, the moments where things stall, and the places where workarounds have quietly filled the gaps left by the legacy system. Laying everything out visually gave us a shared source of truth. It also clarified where the new experience needed to reduce friction, support decision-making, and bring two very different roles into a single, coherent system.
Solution
Solution
The GSAT QA redesign was our chance to untangle a process that had been held together by memory, spreadsheets, and years of personal workaround habits. We set out to replace that patchwork with a single, coherent system built around how QA managers and auditors actually work.
The new tool brings claim assignment, review, scoring, and tracking into one place. QA managers can finally see workload, performance, and compliance metrics without juggling files or relying on what they can remember. QA auditors no longer jump between tools. They can check out a claim, review the initial audit, and complete their assessment in one flow. The dynamic QA form supports accurate reviewing.
Every decision in the redesign came from watching users navigate the old system. The result is a workflow that removes friction and gives the QA team a more dependable way to do their work.
Users
We focused on two primary personas, the QA Manager and the QA Auditor. Over the hours of observing these users, we learned most of them have been in the work for twenty or more years. They developed individual and unique workarounds to account for the fragmented nature of the current state. Understanding these circumstances helped us know that we must account for these workarounds. They have built their own task flows. We can improve their experience while accounting for these unofficial needs. Creating a more efficient way of completing their tasks, while keeping their task flows in tact. Designing within boundaries.
Information Architecture
Insights from user interviews allowed us to identify key user needs and priorities. We then created and used the sitemaps to prioritize critical task flows such as reviewing profiles, assigning claims, checking out claims, and conducting QA reviews.
Low-fidelity
We started with low-fidelity wireframes to map out how QA managers and auditors move through their most essential tasks. Keeping things simple helped us focus on what mattered: the information they need to see, the decisions they make and the steps that define a successful assignment or review. These early sketches gave us space to test ideas quickly and validate with stakeholders, before committing to detailed design.
Limited Visibility and Functionality