Rebecca Jones

Challenge

Claims leakage, meaning funds paid that should not have been, was not being measured. Leaders could not see how much was leaking, where it occurred, or why.

Approach

• Applied headquarters' leakage methodology and helped build detailed definitions and root-cause categories
• Co-designed layered KPIs with Quality and Claims leaders: Financial Accuracy, then Payment Accuracy, then Leakage, then root cause
• Authored about 30 Standards of Practice and quick reference guides
• Partnered directly with 26 business units on rollout

Result

• $7M in annual leakage quantified for the first time
• U.S. accuracy raised from 70% to 85 to 90%, beating the 80% target
• Leakage on examiner-handled U.S. claims cut from 9 to 12% to 4% or less
• U.S. baseline, standards, and targets rolled out as the global standard

Challenge

Examiners struggled with medical documentation requirements, and online claims processed through automation carried leakage of about 30%. Training alone was not closing the gap.

Approach

• Defined claim populations with Business Intelligence and sampled illness, injury, and online claims
• Found that acute illnesses and injuries in the right policy window were almost always covered, while claims filed under the "Other" reason usually were not
• Proposed documentation simplification with Claims and Quality leaders, cleared through compliance review
• Translated findings into pay/deny rules with the RPA developer

Result

• Leakage on automated U.S. claims cut by about 90%, from 30% to under 3%
• Rules designed so covered acute claims did not require unnecessary medical records
• This result became the business case for extending the targets globally

Challenge

Quality reporting was built manually in Excel and took 5 to 6 days after month end. By the time leaders saw a trend, it was already a problem.

Approach

• Authored data requirements for BI-built PeopleSoft extracts, specifying source fields, filter criteria, time frames, and business rules
• Cleansed and shaped the source data, then designed a star-schema data model relating the claims fact table to product, benefit, examiner, team leader, and date dimensions
• Authored DAX measures for Financial Accuracy, Payment Accuracy, and leakage rate by both volume and dollar value
• Designed the report UX: slicers, drill-down hierarchies, KPI conditional formatting against targets, and button-based page navigation, aligned to corporate brand standards
• Validated measures against source data, led user acceptance testing with managers, and published a step-by-step user guide

Result

• Real-time visibility replaced month-end reporting delays
• 26 team leaders and 5 managers trained to self-serve
• Reporting reached audiences up to the COO
• Audit form streamlined from 25 questions to 3 with Quality and Claims leadership