Case Study: Claims Review and Utilization Management Platform
challenge
Utilization management programs coordinating prior-authorization requests across multiple stakeholders often run on disconnected spreadsheets, faxes, and email threads. This causes missed turnaround-time (TAT) and SLA deadlines, duplicate case submissions, uneven nurse workloads, and no single source of truth for audit or compliance. Payers and providers lack visibility into where a case stands, and manual routing between Nurses, Triage Nurses, Medical Directors, and Claims Staff introduces delay and error risk.
solution
Arkenea developed Arc Care as a role-based Utilization Management platform that automates the entire case lifecycle – from provider intake through nurse review, MD decisioning, and claims handoff – with automatic TAT calculation, round-robin case assignment, and system-generated letters, giving every stakeholder real-time visibility into case status.
Arc Care gives healthcare payers and provider networks a single, auditable system of record for utilization management – replacing the manual coordination that used to happen over email and fax, enforcing consistent TAT and SLA compliance across urgent, standard, retrospective, and recurring cases, and giving every role from Provider to Payer real-time visibility into where a case stands.
key highlights
Automated Case Intake & TAT Assignment: Providers create Urgent, Standard, Retrospective, and Recurring UM cases with case-type-specific TAT logic (24 hours, 72 hours, or 30 days), automatic weekend inclusion/exclusion for inpatient vs. outpatient cases, and built-in duplicate-case detection.
Round-Robin Nurse Assignment: Every submitted case is automatically routed to the next available nurse in strict rotation, with inactive nurses skipped and recurring cases re-assigned to their original nurse whenever possible.
Recurring & Concurrent Case Automation: Recurring UM cases auto-generate on frequency completion with prior-case linkage, while inpatient cases support concurrent review requests tied back to the originating case.
Guardrailed Clinical Review Workflow: Nurses, Triage Nurses, and Medical Directors review cases against CPT/ICD data with confirmation prompts on status changes, mandatory notes on regression transitions, and guideline-based CPT-level decisions (Approved / Denied / Partially Approved).
RFI (Request for Information) Automation: When a nurse flags a case as needing more information, the system auto-extends the TAT, generates a structured RFI letter and checklist, and auto-closes the case if the provider misses the response window.
Auto-Generated Compliance Letters: Approval, denial, RFI, and closure letters are system-generated with mandatory fields pre-populated, cutting manual drafting and keeping documentation consistent and audit-ready.
Member & Intake Management: A dedicated Intake Dashboard lets Nurses and Triage Nurses create, search, and manage primary subscriber and dependent profiles, with insurance-eligibility checks run automatically against service dates.
Claims Staff Round-Robin & Payer Handoff: Approved cases flow to Claims Staff through a threshold-controlled round-robin queue and on to Payers for acknowledgment, closing the loop from clinical decision to reimbursement.
Immutable Audit Logging: Every assignment, reassignment, status change, and overdue trigger is logged, with filterable, exportable audit trails available to Super Admins for compliance review.
Secure Document & Comment Threads: Role-based document uploads (PDF/DOCX/JPG, 50MB cap) and time-boxed, character-limited commenting keep provider-nurse communication structured and auditable.
Arkenea helped provide both practical advice and experience that enabled us to launch our website and create complementary mobile applications in a cost effective way while providing ongoing product support into the future. Without Arkenea, this dream would have vanished into oblivion.
